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I
NEW JERSEY
MEDICINE
'HE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY JANUARY 1990
8MEAL1TH SCIENCES LIBRARf
MEDICATION
ERRORS
Y - O - U - R
PRACTICE
MADE MORE
PERFECT
WITH OVERHEAD EXPENSE INSURANCE FROM BLANKSTEEN
If you get sick, we’d like to help keep your practice well with
overhead expense coverage that can reimburse office salaries,
rent, insurance premiums, and utilities during an extended
disability. Your needs are special, so call and talk with us.
The only time to draw a blank in your insurance is when you
fill it in with Blanksteen.
The steen Companies
The Blanksteen Companies 253 Washington Street Jersey City, NJ 07302 201-333-4340 1-800-BLANK-AG
The Blanksteen Companies 161 William Street New York, NY 10038 212-7 32-9435 1-800-BLANK-AG
The MEDICAL SOCIETY OF NEW JERSEY endorsed plans, including Professional 0'’<“neat* Expenie underwritten by National
Casualty Company.
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
27
35
41
Medication trrors:
1977 to 1988
Suzanne L. Kuehm, MPH
Michael J, Doyle, MD
The Contemporary
Alcoholic
Norman S. Milier, MD
MarkS. Gold, MD
Whipple Operation
Revisited
David A. Spain, MD
Ralph S. Greco, MD
45
47
Thomas Jefferson
University:
Tradition and Heritage
Morris H. Saffron, MD
Case Report:
Malignant Fibrous
Histiocytoma
Induced by Thorium
Mark T. DiMarcangelo, DO
Eriberto T. David, MD
Koson Kuroda, MD
■ DEPARTMENTS ■
7 Professional Liability
James E. George, MD, JD
A. Ronaid Rouse
1 1 MSNJ Newsletter
.j -j President’s Page
' Paul J. Hirsch, MD
ty. | Editor’s Desk
Howard D. Slobodien, MD
25 Book Reviews
61 Continuing Education
66 in Memoriam
The Cover: We review the
experience in medical
malpractice claims for
medication errors in a New
Jersey study beginning on
page 27.
Cover: Will Harmuth
Wm NOTEBOOK ■
52 Trustees’ Report
53 UMDNJ Notes
54 Annual Meeting Schedule
55 MSNJ Auxiliary
55 AMNJ Update
56 Legislative Bulletin
58 Placement File
68 Editorial Criteria
4
NEW JERSEY MEDICINE
MCE 5.3/UbUJJ
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MIDLANTIC SPECIALIZES IN
ONE OF THE MOST CRITICAL AREAS
OF YOUR PRACTICE.
Your financial health. Keeping it in tip top condition
demands an inordinate amount of time and attention. Yet,
because your patients must come first, all too often this im-
portant part of your practice suffers. To address this concern
Midlantic National Bank/North created the Medical/Dental
Banking Group.
As professionals in the field, Midiantic’s Medical/Dental
Specialists offer a full range of financial management services.
Whether you’re starting a new practice, purchasing an estab-
lished one or buying into a group practice, our specialists
work with you on an individual basis, every step of the way.
We’ll help secure the loan you need for new equipment,
leasehold improvements or for working capital. If you’re just
starting out, there’s our “Healthy Start” Cash Flow Man-
agement Program— a conveniently scheduled series of one-
on-one consultations for optimal financial returns.
For more information and to receive your copy of
“A Complete Financial Services Program for Health Care
Professionals” call 1-800-633-0400 or (201) 881-5191.
Talk with a Midlantic Medical/Dental Specialist about
your unique financial needs. He’ll help put this critical area
of your practice in excellent condition.
Member FDIC
Equal Opportunity Lender
Midlantic is a registered service mark of Midlantic Corporation.
Midlantic
Midlantic National Bank/North
Hungry Bankers
VOL. 87— NUMBER 1 JANUARY 1990
3
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
105
108
113
115
Sexual Harassment
and Discrimination
Diane K. Shrier, MD
Mesmer and His Critics
Daniel Parish
Spacer-Induced
Atrial Fibrillation
Christopher C. Breeden, MD
Benjamin H. Safirstein, MD
Medical Waste Regulations
Edward A. Hogan, Esq.
Joseph J. McGovern, Esq.
121
127
Cutaneous Malignant
Melanoma
Jonathan O. Nwiloh, MD
Barry Sussman, MD
Rosemary Tambouret, MD
Herbert Dardik, MD
Pasteurella Multocida
Meningitis
Omar Costa-Cruz, MD
Anna Marie Sesso, MD, MPH
Shrikrishna Mate, MD
Elliot Frank, MD
■ DEPARTMENTS
79 MSNJ Newsletter
85 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
NEW JERSEY
medicine
4n*»i'.a
The Cover: Sexual
harassment and
discrimination are
pervasive problems with
serious consequences to
physical and mental health.
Our report begins on page
105. Cover: Frank Cecala
91 President’s Page
Paul J. Hirsch, MD
95 Editor’s Desk
Howard D. Slobodien, MD
99 Book Reviews
101 Letters & Viewpoints
147 In Memoriam
NOTEBOOK
131
Trustees’ Report
132
UMDNJ Notes
132
MSNJ Assessment
135
Placement File
137
Annual Meeting Application
139
Continuing Education
151
Editorial Criteria
153
Classified Advertising
76
NEW JERSEY MEDICINE
■KCI10US WA$n DISPOSAL SOUITIONS FOR
The number one disposal company
on the east coast is expanding its fam-
ily of infectious waste services to
include doctor’s offices and clinics.
BioSystems’ unique disposal service
eliminates your infectious waste prob-
lems with regularly scheduled pick up
and delivery of our own containers by
trained and qualified technicians.
We’ve designed a full line of rigid and
non-rigid containers to handle all of __
your infectious and medical waste.
Just drop it in the box and we’H do the
rest. Pick it up, document it, transport
it, destroy it and leave you fresh con-
tainers at the point of use.
Choose from one of our safe, con-
venient and fully compliant programs
that take the worry out of waste dis-
posal. All for a fixed monthly rate
designed to fit your budget. To help
get you started, we’ll visit your facility
at no charge, and suggest a plan that
suits your needs.
BioSystems is a licensed disposal
service now serving over 85 major
acute care facilities and over 2500
professional offices and clinics in the
eastern U.S. region. All containers are
transported in our own locked vehicles.
Contents are destroyed utilizing only
sound environmental techniques at our
own facilities, eliminating the possibili-
ties of mishandling by subcontractors.
. To find out more fill out this form and
drop it in the mail, or call us at (215)
672-8888.
wmgmmmmmmmmmmmmmmmmagsgg]
Please send me more information on how
to eliminate infectious waste in my facility.
Name Phone
Facility or Institution
Address
City State Zip
Mail to: BioSystems Partners,
380 Constance Drive
Warminster, PA 18979
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
187 Grace Under Pressure:
The First Women To Join the
County Medical Societies of New Jersey
Geraldine R. Hutner, MA
193
Rebecca Hallowell
213
Ruth Clement
219
Emma Clark
Atlantic County
Gloucester County
Morris County
195
Caroline Van Horne
214
Florence De Hart
221
Marie Chard
Bergen County
Hudson County
Ocean County
199
Emma Weeks
oi e
n 1 ■ AN AN f " 1 AN ■» 1 a
223
Ellen Smith
Burlington County
AIICG 1 3 1* K
Hunterdon County
Salem County
201
Sophia Presley
224
Mary Gaston
Camden County
216
S. Mabel Grier
Somerset County
205
Anna Hand
Mercer County
226
Katherine Stewart
Cape May County
216
Caroline Marsh
Sussex County
207
Mary Dunlap
Middlesex County
227
Eleanor Galt
Cumberland County
217
Sarah Mackintosh
Union County
211
Eleanor Haines
Monmouth County
229
Doreen Sheffield
Essex County
Passaic County
Warren County
DEPARTMENTS ■
163 MSNJ Newsletter
173 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
177 President’s Page
Paul J. Hirsch, MD
181 Editor’s Desk
Howard D. Slobodien, MD
185 Book Reviews
245 In Memoriam
mm NOTEBOOK ■■
231 Annual Meeting Application
233 Trustees’ Report
234 UMDNJ Notes
235 MSNJ Auxiliary
235 Annual Meeting Schedule
236 Placement File
238 Continuing Education
247 Editorial Criteria
249 Classified Advertising
160
NEW JERSEY MEDICINE
SOI-
08-
01
09-
09-
Ot-
oei
3
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Jt/
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W
I s 3 S S S S sm
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inject
the only
full cycle solution
into your
medical waste
# liability. «
s
3 S S S § 8 Si
M
A
Systematic “generation-to-incineration”
management, documentation and
service. It’s the best method to comply
with the tough new medical waste laws,
assure office safety and minimize generator
liability. MSD’s Full Cycle System includes
on-call pickup, complete handling, and
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line includes leak-proof,
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minimize exposure while
in use . . . bactericidal/
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ment ... and solidifying
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30
40
iso
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analysis and regular reporting
ensure further proof of proper
disposal ... and this data can
be applied to your required
periodic regulatory agency report-
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small generator.
Protect yourself and
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become part of the
cure ... with the Medical
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.7.cn Solid Waste Technologies, Inc.
trom MSD. 50 Mount Bethel Road
Warren, NJ 07060
Phone: 201-757-4414
800-548-9789
FAX: 201-561-7319
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
291
Long Odyssey of
Babesiosis
Sandra W. Moss, MD
297
Cancer Recurrent at
Stapled Colon Incision
J. Thomas Davidson, MD
Lucius D. Clay, III, MD
Michael Umanoff, MD
James J. Chandler, MD
305
Clinical Decision
Making
Howard Holtz, MD
Leonard Bielory, MD
Neil Freund, MD
Norman Lasker, MD
311
Hazards Smokers
Impose
K.H. Ginzel, MD
301 Colonic Lipomas
Geobel A. Marin, MD
Gabriele L. Villa, MD
319
Idiopathic Chronic
Fatigue
Robert J. Van Amberg, MD
327 Report of the
Nominating Committee
DEPARTMENTS
261
MSNJ Newsletter
269
Professional Liability
James E. George, MD, JD
A. Ronald Rouse
273
President’s Page
Paul J. Hirsch, MD
277
Editor’s Desk
Howard D. Slobodien, MD
283
Letters & Viewpoints
287
Book Reviews
345
In Memoriam
We present the detectives
who uncovered the clinical
and epidemiological
features of human
babesiosis. The story
begins on page 291 .
Photography: Stan Godlewski
NOTEBOOK
331
Trustees’ Report
332
UMDNJ Notes
333
MSNJ Auxiliary
334
AMNJ Report
335
Placement File
338
Continuing Education
348
Editorial Criteria
351
Classified Advertising
256
NEW JERSEY MEDICINE
IIWOVATIVE MEDICAL SYSTEMS, IMC.
. . . Doing what WE DO BEST, so you
can do what you do best
THE IMS ADVANTAGE
• IMS has demonstrated its success by INCREASING
COLLECTIONS AMD CASH FLOW WHILE
ENHANCING THE PHYSICIAN'S PROFESSIONAL
IMAGE
• IMS is a fully BONDED ORGANIZATION OF MEDICAL
MANAGEMENT SPECIALISTS with over 15 years
experience in practice management.
FOR INFORMATION CONTACT: 609-770-1160
GLEHDALE EXECUTIVE CAMPUS • 1000 WHITE HORSE ROAD
SUITE 512 • VOORHEES, HEW JERSEY, 08043
VOL. 87— NUMBER 4 APRIL 1990
255
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
393
Medical Malpractice Claims
in Cardiology
Suzanne L. Kuehm, MPH
Emanuel Abraham, MD
413
Tuberculosis, AIDS, and
IV Drug Abuse
R.J. Lamb, PhD
I -Tien Yeh, MD
401
Malignant Melanoma
of the Skin
Kristen Mertz, MD
Henry C. Lewis, Jr, MPH
Lawrence A. Meinert, MD, MPH
41 7 MinoritV Health Status
in New Jersey
George Hampton
Douglas H. Morgan
Billie Slaughter, PhD
409
Luetic Aortic Aneurysm
Jock N. McCullough, MD
Ronald M. Abel, MD
421
Professional Medical
Conduct Reform Bill
Michael B. Grossman, DO
DEPARTMENTS
365
Professional Liability
James E. George, MD, JD
A. Ronald Rouse
369
MSNJ Newsletter
379
President’s Page
Paul J. Hirsch, MD
381
Editor’s Desk
Howard D. Slobodien, MD
385
Book Reviews
389
Letters & Viewpoints
433
In Memoriam
NEW JERSEY
MEDICINE
To decrease patient injury
and lower the incidence of
malpractice suits, MIIENJ
analyzed data from its files
The story begins on page
393.
m
Cover: Will Harmuth
• IttUWCnCE OJWS M CAffltCtOGY
NOTEBOOK
423
Trustees’ Report
424
UMDNJ Notes
425
MSNJ Auxiliary
426
New Members
427
Placement File
429
Continuing Education
435
Editorial Criteria
437
Classified Advertising
360
NEW JERSEY MEDICINE
atUSAA
When you compare auto or
homeowners insurance, look at all
the variables.
Do you get the kind of service you
deserve? Are your insurance rates
competitive? Do you earn dividends?
Do you share in the company's
profits?
At USAA, the bottom line is
VALUE. You save both time and
money when you insure with us.
Here’s why.
SELECT, ECONOMICAL
Because of your military affiliation,
you may be eligible to join USAA — a
very select group. We take pride in
knowing that the members we serve
(current and former commissioned
and warrant officers in the U.S. armed
forces) are responsible and mature
drivers and property owners.
Because of the Association's
selectivity, our insurance rates are
highly competitive, highly desirable.
But favorable rates are just a part of
the USAA story.
We offer safe driver dividends,
multiple car and carpooler discounts.*
When you protect your new home
with USAA coverage, you can save up
to 20%. And save even more by
installing an approved fire and burglar
protection system.
When you insure with USAA, you
become an owner of the Association.
And, down the road, you'll share in
the company's profits through the
Subscriber's Savings Account.
TOPS IN SERVICE
Our economical coverage may
bring you to us, but our service will
USAA
keep you with us. Speedy policy and
claims service is bottom line. Just ask
your friends who are already USAA
members. And, we're always just a
phone call away.
INSURANCE AND OTHER
FINANCIAL SERVICES
USAA — a unique company which
offers you more than auto and
homeowners protection. One call can
connect you to our experts in life and
health insurance, mutual funds,
banking services, travel, buying
services. A one-stop approach to meet
your special needs, designed to SAVE
YOU TIME AND MONEY.
ONE FREE CALL
You'll find out why 9 out of 10
active duty military officers save time
and money with USAA. Request a free
auto or homeowners insurance rate
quote. There's no obligation. Then
consider the "big picture." We think
you'll save with USAA. Call us today.
1-800-531-8185
'Safe driver dividends are no I available in California.
Those eligible for USAA membership include anyone who is now or ever has been an officer in the U.S.
military. In addition, cadets/midshipmen of the U.S. military academies,
OCS/OTS candidates, ROTC cadets under government contract, and other candidates for commission
are also eligible to apply for membership
VOL. 87— NUMBER 5 MAY 1990
359
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
471 Inaugural Address
Douglas M. Costabile, MD
47C Panic Disorder & Agoraphobia
Morton Fier, MD
A7 Q Claustrophobia During
^ ^ MR Imaging
Roger B. Granet, MD
Lawrence J. Gelber, MD
485 Cancer in
Inguinal Hernias
James W. Knecht, MD
488 Radiol°gy Rounds: Cystic
James H. Jacoby, MD
489 Marketing the
** Technologist in the
Physician Office
Laboratory
Kathleen L. Voldish, CLA
400 Contraceptive Use for
Planned Parenthood
Patients
Lewis E. Savel, MD
496 A Successful Partnership
Stephanie Lichtman, MPA
Joseph Gorrell, JD
Right Upper Quadrant Mass
DEPARTMENTS
449 MSNJ Newsletter
455 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
459 Editor’s Desk
Howard D. Slobodien, MD
Douglas M. Costabile, MD,
is the 198th president of the
Medical Society of
New Jersey.
NOTEBOOK
463 Book Reviews
467 Letters & Viewpoints
500 Golden Merit Award
Recipients
508 In Memoriam
502 Trustees’ Report
503 UMDNJ Notes
504 MSNJ Auxiliary
504 Placement File
507 Continuing Education
509 Editorial Criteria
513 Classified Advertising
444
NEW JERSEY MEDICINE
Magnetic Resonance Imaging
(609) 983-5599
(within 24 hours, off sii
An Affiliate of NMR of America, Inc.
TO OBTAIN MORE INFORMATION ABOUT MAGNETIC RESONANCE (MRI)
Name _
Address
Send Me:
Mail Requests to:
MRI Case Study
Information
Scheduling
Information
NMR of America
Attn: Physician Outreach Dept.
355 Madison Avenue
Morristown, NJ 07960
Phone
Other (Specify) Or Call:
(201) 539-1082
VOL. 87— NUMBER 6 JUNE 1990
443
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
541
Lyme Disease:
Prevention and Control
Anita S. Curran, MD, MPH
563
Neurological Manifestations
of Lyme Disease
Andrew R. Pachner, MD
544
Psychological Impact
of Media Coverage
Mary E. Swigar, MD
567
Immunology of
Lyme Disease
Leonard H. Sigal, MD
549
Clinical Manifestations of
Lyme Disease
Leonard H. Sigal, MD
573
Lyme Disease in
Small Animals
Barry A. Lissman, DVM
557
Lyme Disease
During Pregnancy
Sandra J. Edly, MD
575
Lyme Disease in
Large Animals
John E. Post, DVM, PhD
cyq Lyme Disease in New Jersey
*** ^ Marcia J. Goldoft, MD, MPH; Terry L. Schulze, PhD;
William E. Parkin, DVM, DrPh; Robert A. Gunn, MD, MPH
DEPARTMENTS
525 MSNJ Newsletter
531 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
535 Editor’s Desk
Howard D. Slobodien, MD
537 Book Reviews
539 Special Issue: Lyme Disease
in New Jersey
589 Continuing Education
593 In Memoriam
Highlights from a two-day
symposium on Lyme
disease are presented in
this special issue, to help
readers explore the
disease.
Cover: Frank Cecala
NOTEBOOK
585
UMDNJ Notes
586
MSNJ Auxiliary
587
Interest Charges
587
Placement File
591
Lyme Disease Issue
595
Editorial Criteria
597
Classified Advertising
520
NEW JERSEY MEDICINE
Short cuts and quick fixes can compromise your staff’s
safety, your practice’s reputation, and expose you to stiff non-
compliance tines. . . or worse. MSD’s Full Cycle Solution is
practice-tailored for utmost safety, compliance, and economy
with . . . on-call service visits, complete handling, NJDEP docu
mentation, incineration, computer monitoring ... and
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directly to you.
Our products are also practice-tailored to maximize
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Don't compromise safety and expose your practice to
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IBB
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VOL. 87— NUMBER 7 JULY 1990
519
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
631
637
641
Tracheal Stenosis
Jean-Philippe Bocage, MD
Robert Caccavale, MD
Ralph Lewis, MD
Glenn Sisler, MD
James MacKenzie, MD
Kallmann’s Syndrome:
Reproductive Success
Michael Goldman, MD
Albert Riddle, MD
Eugene Markham, MD
Clinical
Decision Making
Howard Holtz, MD
Robert Restifo, DO
648
Thrombolytic Therapy
Nicholas J. Schneeman, MD
Elliott M. Stein, MD
651
653
674
Pelvic Papillary Neoplasia
Along the Round Ligament
Simulating Inguinal Hernia
Bernard Peison, MD
Barry Benisch, MD
Anthony Tonzola, MD
Radiology Rounds:
Calcified Liver
Lesions
James H. Jacoby, MD
Francis X. O’Brien, MD
Pneumothorax:
Complication of Needle
EMG of Thoracic Wall
Jeffrey Miller, DO
1990 Transactions
of the Medical
Society of New Jersey
DEPARTMENTS
607 MSNJ Newsletter
615 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
619 Editor’s Desk
Howard D. Slobodien, MD
623 Book Reviews
627 Letters & Viewpoints
661 Continuing Education
667 MSNJ Annual Meeting
NEW JERSEY
MwSc* Soc«x>
1990 Tran
We present the reports and
the actions of the 1 990
Medical Society of New
Jersey Annual Meeting.
Cover: Jean Hough
NOTEBOOK
655 Trustees’ Minutes
658 UMDNJ Notes
658 New Members
659 Placement File
659 Lyme Disease Issue Update
673 Editorial Criteria
675 Classified Advertising
604
NEW JERSEY MEDICINE
atUSAA
When you compare auto or
homeowners insurance, look at all
the variables.
Do you get the kind of service you
deserve? Are your insurance rates
competitive? Do you earn dividends?
Do you share in the company's
profits?
At USAA, the bottom line is
VALUE. You save both time and
money when you insure with us.
Here's why.
SELECT, ECONOMICAL
Because of your military affiliation,
you may be eligible to join USAA — a
very select group. We take pride in
knowing that the members we serve
(current and former commissioned
and warrant officers in the U.S. armed
forces) are responsible and mature
drivers and property owners.
Because of the Association's
selectivity, our insurance rates are
highly competitive, highly desirable.
But favorable rates are just a part of
the USAA story.
We offer safe driver dividends,
multiple car and carpooler discounts.*
When you protect your new home
with USAA coverage, you can save up
to 20%. And save even more by
installing an approved fire and burglar
protection system.
When you insure with USAA, you
become an owner of the Association.
And, down the road, you'll share in
the company's profits through the
Subscriber's Savings Account.
TOPS IN SERVICE
Our economical coverage may
bring you to us, but our service will
USAA
keep you with us. Speedy policy and
claims service is bottom line. Just ask
your friends who are already USAA
members. And, we're always just a
phone call away.
INSURANCE AND OTHER
FINANCIAL SERVICES
USAA — a unique company which
offers you more than auto and
homeowners protection. One call can
connect you to our experts in life and
health insurance, mutual funds,
banking services, travel, buying
services. A one-stop approach to meet
your special needs, designed to SAVE
YOU TIME AND MONEY.
ONE FREE CALL
You'll find out why 9 out of 10
active duty military officers save time
and money with USAA. Request a free
auto or homeowners insurance rate
quote. There's no obligation. Then
consider the "big picture." We think
you'll save with USAA. Call us today.
1-800-531-8185
'Safe driver dividends are not available in California.
Those eligible for USAA membership include anyone who is now or ever has been an officer in the U.S.
military. In addition, cadets/midshipmen of the U.S military academies,
OCS/OTS candidates, ROTC cadets under government contract, and other candidates for commission
are also eligible to apply for membership
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW |ERSEY
CONTRIBUTIONS
703
Pediatric Cancer
Mortality Rates
Dona Schneider, PhD
Michael R. Greenberg, PhD
Bonnie Stach, MCRP
723 physicians’
Office Laboratories
Kathleen L. Voldish,
CLA (ASCP)
71 *5 Intussusception in
f Childhood
Irwin H. Krasna, MD
Bonna G. Benjamin, MD
Jeffrey L. Zitsman, MD
David Rosenfeld, MD
727
Focal Candida
Hepatitis in a Patient
with Richter’s Syndrome
J.G. Barone, MD
C.A. Abouchedid, MD
R.L. Moser, MD
731 Polyposis Coli and Gardner’s Syndrome
W. Mark Nannery, MD
Joseph G. Barone, MD
Claude Abouchedid, MD
DEPARTMENTS
685 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
689 MSNJ Newsletter
695 Editor’s Desk
Howard D. Slobodien, MD
699 Book Reviews
739 Continuing Education
747 In Memoriam
NEW JERSEY
MEDICINE
Our report on pediatric
cancer mortality rates for
the 25-year study period
begins on page 703.
Cover: Will Harmuth
NOTEBOOK
735
Trustees’ Minutes
736
MSNJ Auxiliary
737
AMNJ Report
737
Placement File
743
Special Issue Orders
751
Editorial Criteria
756
Classified Advertising
682
NEW JERSEY MEDICINE
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■ Flexible approaches to data collection using hospital data through electronic media inter-
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□ We utilize tape-to-tape interface to submit weekly claims to Medicare, Medicaid and
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CREDIT AND COLLECTIONS
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■ Acknowledgements — all new accounts
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■ Trial balances of open accounts
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Prime Mark is incorporated in the state of New Jersey as a collection agency.
To find out more about how Prime Mark can improve your billing and/or bad debt
collections call Joseph W. Delaney at 201-669-8987.
VOL. 87— NUMBER 9 SEPTEMBER 1990
681
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
803
785 health Access New Jersey
Position Paper of the
Medical Society of New Jersey
701 *-e9a* Implications of
Routine Screening
for Asymptomatic Silent
Myocardial Ischemia
Leon G. Smith, MD
Richard E. Brennan, ESQ
Kathleen H. Dooley, ESQ
795 Carotid Endarterectomy
Under Local Anesthesia
Kenneth S. Fried, MD
Steven M. Elias, MD
Robert Raggi, MD
799 Maintaining an
Office Laboratory
Kathleen L. Voldish, CLA (ASCP)
811
Carcinoma of the
Male Breast
Jeffery W. Seitzinger, MD
Squamous Cell Cancer
of the Larynx in an
IV Drug User with AIDS
J.G. Barone, MD
D. Hutchinson, MD
A.L. Cuppari, MD
J.E. Barone, MD
81 5 Parathyroid Adenoma
Michael H. Goldman, MD
Arati Suresh, MD
819
Medical Services for
the Developmentally
Disabled
Ted Kasiner, MD
Joan Luckhardt, PhD
DEPARTMENTS
767 MSNJ Newsletter
773 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
777 Editor’s Desk
Howard D. Slobodien, MD
781 Book Reviews
827 Continuing Education
833 In Memoriam
NEW JERSEY
Health Access
New Jersey
The Medical Society of New
Jersey offers proposals to
strengthen the New Jersey
health care system. The
position paper begins on
page 785.
Cover: Frank Cecala
NOTEBOOK
760
MSNJ Officers/Trustees
824
UMDNJ Notes
825
MSNJ Auxiliary
825
Placement File
835
Editorial Criteria
839
Classified Advertising
762
NEW JERSEY MEDICINE
Q q f\C\
«t>1 #2*
I »
» JOW*
MIDLANTIC SPECIALIZES IN
ONE OF THE MOST CRITICAL AREAS
OF YOUR PRACTICE.
Your financial health. Keeping it in tip top condition
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Midlantic National Bank/North created the Medical/Dental
Banking Group.
As professionals in the field, Midiantic’s Medical/Dental
Specialists offer a full range of financial management services.
Whether you’re starting a new practice, purchasing an estab-
lished one or buying into a group practice, our specialists
work with you on an individual basis, every step of the way.
We’ll help secure the loan you need for new equipment,
leasehold improvements or for working capital. If you’re just
starting out, there’s our “Healthy Start” Cash Flow Man-
agement Program— a conveniently scheduled series of one-
on-one consultations for optimal financial returns.
To discuss your unique financial needs and to receive
your copy of “A Complete Financial Services Program for
Health Care Professionals” call Midiantic’s Patrick Robin-
son, Vice President, Group Manager at 1-800-633-0040 or
(201) 881-5191. He’ll help put this critical area of your prac-
tice in excellent condition.
Member FDIC
Equal Opportunity Lender
Midlantic is a registered service mark of Midlantic Corporation.
Midlantic
Midlantic National Bank/North
Hungry Bankers
VOL. 87— NUMBER 10 OCTOBER 1990
761
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CONTRIBUTIONS
871
873
881
889
895
901
Medical Research in New Jersey
Alan J. Lippman, MD, Guest Editor
Innovative Methods of
Cardiac Defibrillation
Lawrence J. Gessman, MD
Laser Energy for
Tachycardia Ablation
Sanjeev Saksena, MD
Cancer Research in New Jersey
Ann Marie Hill; Frederick B. Cohen, MD
Biologic Therapy of Cancer
Alan W. Dunton, MD; John Hanagan, MD;
Daniel Levitt, MD, PhD;
Robert J. Spiegel, MD; Jacob Zeffren, MD
Responsible Weight Loss in New Jersey
Marvin A. Kirschner, MD;
George Schneider, MD;
Norman Ertel, MD; Anton Heins, III, MD;
Patricia McAleavy, MSW;
Maryann Merrell, RD
907 Research in Sleep Medicine
Jeffrey Nahmias, MD; Monroe Karetzky, MD
913
Monoclonal Antibody Therapy of Cancer
David M. Goldenberg, ScD, MD;
Robert M. Sharkey, PhD;
Hildegard Goldenberg, MD;
Thomas C. Hall, MD; Sumathi Murthy, MD;
Daniel 0. Izon, MD; Pedro Gascon, MD;
Lawrence C. Swayne, MD
919 Nuclear Cardiology; Perfusion,
Viability, and Function
Margaret LaManna, MD
923 Vascular Surgery and Cardiac Pacing
David E. Eisenbud, MD
927 New Jersey Pediatric Hematology Oncology
Milton H. Donaldson, MD
931 Surfactant Replacement Therapy
Jeffrey R. Greenwald, MD;
I. Mark Hiatt, MD;
Thomas Hegyi, MD
DEPARTMENTS
851
MSNJ Newsletter
857
Professional Liability
James E. George, MD, JD
A. Ronald Rouse
861
Editor's Desk
Howard D. Slobodien, MD
865
Book Reviews
938
Statement of Ownership
941
Quality of Life and Health
Theresa H. Hauber, MPH
944
Annual Meeting Application
946
Continuing Education
952
In Memoriam
NEW jEi^ftL
MEDICINE
R
This special issue focuses
attention on medical
research in New Jersey,
and the far-reaching effects
of such progress.
Cover: Jean Hough
NOTEBOOK
939
Trustees’ Report
940
UMDNJ Notes
941
MSNJ Auxiliary
942
MSNJ Directory
942
Placement File
943
Annual Meeting Schedule
957
Classified Advertising
954
Editorial Criteria
846
NEW JERSEY MEDICINE
may be bronchitis
Brief Summary.
Consult tta package literature for prescribing information.
Indication: Lower respiratory infections, including
pneumonia, caused by Streptococcus pneumoniae,
Haemo0ilus influenzae, and Streptococcus pyogenes
(group A p-hemolytlc streptococci!.
Contraindication: Known allergy to cephalosporins.
Warnings: CECLOR SHOULD BE ADMINISTERED
CAUTIOUSLY TO PENICILLIN-SENSITIVE PATIENTS.
PENICILLINS AND CEPHALOSPORINS SHOW PARTIAL
CROSS-ALLERGENICITY. POSSIBLE REACTIONS
INCLUDE ANAPHYLAXIS.
Administer cautiously to allergic patients.
Pseudomembranous colitis has been reported with
virtually alt broad-spectrum antibiotics. It must be con-
sidered In differential diagnosis of antibiotic-associated
diarrhea. Colon flora is altered by broad-spectrum
antibiotic treatment, possibly resulting in antibiotic-
associated colitis.
Precautions:
• Discontinue Ceclor m the event of allergic reactions to it.
• Prolonged use may result in overgrowth of non-
susceptible organisms.
• Positive direct Coombs’ tests have been reported
during treatment with cephalosporins.
■ Ceclor should be administered with caution In the
presence ot markedly impaired renal function. Although
dosage adjustments in moderate to severe renal
Impairment are usually not required, careful clinical
observation and laboratory studies should be made.
• Broad-spectrum antibiotics should be prescribed with
caution in individuals with a history of gastrointestinal
disease, particularly colitis.
• Safety and effectiveness have not been determined In
pregnancy, lactation, and infants less than one month
old. Ceclor penetrates mother's milk. Exercise caution
in prescribing for these patients.
Adverse Reactions: (percentage of patients)
Therapy-related adverse reactions are uncommon.
Those reported include:
• Hypersensitivity reactions have been reported in about
1.5% of patients and include morbilliform eruptions
(1 in 100). Pruritus, urticaria, and positive Coombs’
tests each occur hi less than 1 in 200 patients. Cases
of serum-sickness-llke reactions have been reported
with the use of Ceclor. These are characterized by
(hidings of erythema multitorme, rabies, and other skin
manifestations accompanied by aithritis/arttiralgia, with
of without fever, and differ from classic serum sickness
and proteinuria, no circulating immune complexes, and
no evidence to date of sequelae of the reaction. While
further investigation is ongoing, serum- sickness-itke
reactions appear to be due to hypersensitivity and more
often occur during or following a second (or subsequent!
course of therapy with Ceclor. Such reactions have been
reported more frequently m children than in adults with
an overall occurrence ranging from 1 in 200 (0.5%) in
one focused trial to 2 in 8,346 (0.024%) in overall
clinical trials (with an incidence in children in clinical
trials of 0.055%) to 1 in 38,000 (0.003%) in spon-
taneous event reports. Signs and symptoms usually
occur a few days after initiation of therapy and subside
within a few days after cessation of therapy; occasion-
ally these reactions have resulted In hospitalization,
usually of short duration (median hospitalization = two
to three days, based on postmarketing surveillance
studies). In those requiring hospitalization, the symp-
toms have ranged from mild to severe at the time of
admission with more of the severe reactions occurring
In children. Antihistamines and glucocorticoids appear
to enhance resolution of the signs and symptoms. No
serious sequelae have been reported.
• Stevens-Jobnson syndrome, toxic epidermal necrolysis,
and anaphylaxis have been reported rarely. Anaphylaxis
may be more common in patterns with a history of
penicillin allergy.
• Gastrointestinal (mostly diarrhea): 2.5%
• Symptoms of pseudomembranous colitis may appear
either during or after antibiotic treatment.
• As with some penicillins and some other cephalo-
sporins. transient hepatitis and cholestatic jaundice
have been reported rarely.
• Rarely, reversible hyperactivity, nervousness, insomnia,
confusion, hypertonia, dizziness, and somnolence have
■ Other: eosinophitia, 2%; genital pruritus or vagfnttis,
less than 1% and, rarely, thrombocytopenia and reversible
interstitial nephritis.
Abnormalities m laboratory results of uncertain etiology.
• Slight elevations in hepatic enzymes.
• Transient lymphocytosis, leukopenia, and. rarely,
hemolytic anemia and reversible neutropenia.
• Rare reports of increased prothrombin time with or
without clinical bleeding in patients receiving Cedar
and Coumadin concomitantly.
• Abnormal urinalysis; elevations in BUN or serum
creatinine.
• Positive direct Coombs' test
• False-positive tests for urinary glucose with Benedict's
or Fehling’s solution and CIfnitest* tablets but not with
Tes-Tape* (glucose enzymatic test strip, Lilly).
PA 8791 AMP (021490 lf8)
Additional information available to the profession
on reguest from Eli Lilly and Company, Indianapolis,
Indiana 46285.
EH Lilly Industries, Inc
Carolina, Puerto Rico 00630
A Subsidiary of Ell Lilly and Company
Indianapolis, Indiana 46285
CR-0525-B-049333 © 1990, EU LILLY AM COMPANY
“Recent research
has delineated
early, more subtle
changes in lung and
immune functions. These
alterations directly
predispose smokers to
respiratory tract infection.”
Am Fam Phys 1987;36:133 140
Established therapy
for today’s patients
For respiratory tract Infections due to
susceptible strains of indicated organisms
VOL. 87— NUMBER 11 NOVEMBER 1990
845
II
NEW JERSEY
MEDICINE
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW |ERSEY
CONTRIBUTIONS
983
Professional Review
and Regulations
James E. George, MD, JD
Madelyn S. Quattrone, JD
Joann Phillips, CMSC
1005
QQQ Professional Medical
Conduct Reform Act
995
1001
Sean Patrick Murphy, JD
Maternal Deaths in
New Jersey: 1988
Gerard F. Hansen, MD, MPH
Ronald A. Chez, MD
Crack-Induced
Enteric Ischemia
David C. Hon, MD
Leslie J. Salloum, MD
Howard W. Hardy, III, MD
James E. Barone, MD
1009
1011
Noninvasive Diagnosis
of Deep Vein
Thrombosis
Edward G. Moss, MD
James Alexander, MD
Profiles in Medicine:
Nicholas A. Bertha, MD
Nancy M. Propsner
Antisense DNA-
Analogs: Inhibition
of Human Immuno-
deficiency Virus
Yon Ebright, PhD
Karel Raska, Jr, MD
Sunanda Gaur, MD
Lawrence Frenkel, MD
Jonglin Tsao
Stanley Stein, PhD
1045
1990 NEW JERSEY MEDICINE Index
DEPARTMENTS
965 MSNJ Newsletter
971 Professional Liability
James E. George, MD, JD
A. Ronald Rouse
UTaTT
&
«, *» I
If
mm mS*
8 if
V JERSEY MEDICINE 19»
The 1990 year-end index is
included in this issue of
NEW JERSEY MEDICINE,
beginning on page 1045.
The journal also is
abstracted in Index
Medicus.
975 Editor’s Desk
Howard D. Slobodien, MD
979 Book Reviews
1016 Committees & Councils
1023 Liaison Representatives
NOTEBOOK
1029
Trustees’ Minutes
1030
UMDNJ Notes
1031
Presidential Address
1033
New Members
1034
Placement File
1037
Continuing Education
1042
In Memoriam
1044
Editorial Criteria
962
NEW JERSEY MEDICINE
The Committee on Publication,
the Editorial Board,
and the Staff of
the award-winning
NEW JERSEY MEDICINE
would like to thank all our
readers and advertisers
for a successful 1 990.
w a,
\J'0'yC'U4' $€6404*
A
HMH VtMsj
VOL. 87— NUMBER 12 DECEMBER 1990
961
MERIN ADOPTS MALPRACTICE SURCHARGE
In an effort to address a $65 million deficit and to
cover-up ineffective regulatory action and negligent
management, Insurance Commissioner Kenneth Merin
announced the adoption of his ill-advised medical
malpractice surcharge proposal.
The Medical Society of New Jersey (MSNJ) and the
Medical Inter-Insurance Exchange of New Jersey
(MIIENJ) have filed suits in the appellate division
of the Superior Court contesting Merin' s decision.
Another MSNJ suit to require Merin to proceed against
the Property-Liability Guaranty Association has been
appealed to the appellate division and will be
consolidated with the other suits.
Neither the New Jersey Hospital Association nor the
Princeton Insurance Company is objecting to the
surcharge .
MSNJ believes this protracted and bitter litigation
ultimately will be decided by the State Supreme
Court .
MEDICAL WASTE BILL AWAITS ACTION BY GOVERNOR
A new medical waste bill has been passed by both the
Assembly and the Senate. It provides for a much
lower fee schedule. Generators with under 50 pounds
per year would pay $100. Further, under its
regulation, the Department of Environmental
Protection is required to make refunds of fees
collected which exceed that amount.
MEDICAL LICENSING REFORM
S-2936 has passed both the Senate and the Assembly
and awaits the governor's signature. This bill
reforms the medical licensing and discipline system
in New Jersey. It assures patients that physicians
with impairments are not a risk to the public health
while providing an unbiased and fundamentally fair
review process for doctors.
in
.
'
PROFESSIONAL
LIABILITY
HOW TO CONDUCT
PEER REVIEW
RULE 1
RULE 2
RULE 3
RULE 4
RULE 5
RULE 6
RULE 7
Comprehensive guidelines for the conduct of peer review are contained
in the Health Care Quality Improvement Act of 1986. It is not necessary
to follow those guidelines to the letter in order to have fair procedures.
The guidelines provide a good framework. In general, hospitals, medical
staffs, and peer reviewers should observe the following guidelines:
In any situation where it appears that a disciplinary proceeding may be
instigated against a physician that could result in the substantial loss
or termination of the physician’s clinic privileges, the advice and guid-
ance of legal counsel should be sought by those persons who are involved
in this phase of the peer review process. The attorney’s participation
should continue in preparation for the hearing including the written
notice of charges, the marshalling of evidence and the facts, and the
selection of witnesses. The attorney should be instructed that his role
is not that of a prosecutor, but as an advisor in assuring that the
proceedings are conducted fairly, bearing in mind the objective of
protecting consumers of health care and the physician involved against
false or exaggerated charges.
The attorney advising the hearing panel and the attorney representing
the physician involved in the proceeding should be accorded reasonable
latitude in cross-examination, but acrimony should not be allowed by
the hearing panel.
Substantial latitude should be permitted in the presentation of evidence,
medical reference works, and testimony, within reasonable time con-
straints and the discretion of the hearing panel.
A court reporter should be present to make a verbatim transcript of the
hearing that should be available to the parties and paid for by the
hospital or health care entity.
Within the discretion of the hearing panel, witnesses may be requested
to testify under oath.
The hearing panel should consist of physicians, none of whom are direct
economic competitors with the physician involved or who stand to gain
through a recommendation or decision adverse to the physician. It is
desirable that members of the hearing panel be physicians who have the
respect of the medical community, but they need not be in the same
specialty as the physician involved.
Physicians who are direct economic competitors of the physician in-
volved may testify as witnesses whether they are called by the physician,
the hearing panel, or the hospital, but a physician should not be deprived
of his privileges solely on the basis of medical testimony by economic
competitors. In any proceedings that result in the termination of privi-
leges, there should be testimony from one or more physicians who are
not economic competitors or who do not stand to gain economically by
VOL. 87— NUMBER 1 JANUARY 1990
7
RULE 8
an adverse action, but who are knowledgeable in the treatment, patient
care management, and areas of medical practice or judgment upon which
the adverse action is based.
When investigation indicates that a disciplinary proceeding is warranted
for the purpose of terminating a physician’s hospital privileges, he should
not be permitted to resign without a finding that his termination oc-
curred without cause. The disciplinary proceedings should be conducted
by the hearing panel with the presentation of testimony and evidence,
irrespective of whether the physician involved chooses not to be present.
(Reprinted with permission from The Citation, American Medical
Association, Volume 59, July 15, 1989)
HEDONIC DAMAGES
CONCEPT GROWING
Hedonic damages, or the loss of pleasure derived from the pursuits of
life, appear to be on the increase. That is the conclusion reached by Ted
Miller, an economist at the Urban Institute, a Washington, DC, think
tank, in a forthcoming study to be published this fall by the North-
western University Law Review.
According to Wall Street Journal columnist Paul M. Barret, Miller’s
study shows that “despite fierce opposition by defense lawyers, the idea
is quickly gaining acceptance.”
As of early July, courts in Connecticut, Mississippi, New Mexico, and
New York had accepted hedonic damages, and lawyers have introduced
such damages with varying degrees of success in cases in an additional
27 states.
Properly “fine-tuned,” the economist warns that hedonic damages could
yield a value between $1 and $1.5 million for a person 38 years of age.
The problem is that “some overly high awards” could result, posing a
lot of headaches for the insurance industry and defense attorneys.
Miller’s advice is to accept hedonic damages as a legitimate measure,
but learn to fight for their appropriate application. ( Medical Liability
Monitor, September 29, 1989)
JUDGES GET
SUED TODAY
Judges, whose immunity against liability actions has been diminished
by recent court decisions, are increasingly buying protection, according
to a recent Wall Street Journal article.
“Judges are sued far more often than the public would believe,” said
Kent Batty, court administrator for the state courts in Wayne County,
Michigan. “And for the past few years, there has been a mounting
concern over liability.”
Judge Phillip J. Roth of the Oregon Supreme Court said, “Judges realize
now that one moment they can be on the bench and the next, they are
in the pit being defended.” Judge Roth, chairman of the Judicial Im-
munity Committee of the American Bar Association, stated at least 800
suits are filed against judges each year.
One insurance broker estimates that about 3,000 state judges and 300
federal now carry liability policies. ( Medical Liability Monitor, August
25, 1989)
PROFESSIONAL
LIABILITY
James E. George, MD, JD, is the director of the Department of Pro-
fessional Liability Control, Medical Society of New Jersey. If you have
any questions, concerns, or complaints about your professional liability,
please contact A. Ronald Rouse, director of Special Projects, Medical
Society of New Jersey, Two Princess Road, Lawrenceville, NJ.
8
NEW JERSEY MEDICINE
MSNJ
NEWSLETTER
1989 MEDICARE The Hospital Rate-Setting Commission (HRSC) approved the revised
COST SHIFT Medicare Cost Shift methodology for 1989 at its October 27, 1989, meet-
APPROVED revised statewide Medicare shortfall now is estimated by the
Department of Health to be approximately $116 million, up from the
previous estimate of $34 million. Approximately 70 percent of Chapter
83 hospitals are expected to have a shortfall of Medicare payments in
1989. The Department anticipates incorporating the new cost shift
amounts into hospital November markup factors. In order to mitigate
the impact of wide changes in markup factors as a result of the an-
nualization of these cost shifts over the last two months of 1989, the
Department will adjust the markup factors based on a corridor policy
that also was approved by HRSC.
NEW DIRECTOR The Department of Health announced that Anne Weiss has been ap-
OF HOSPITAL P°inted as the director of hospital reimbursement at the Department
REIMBURSEMENT health. The appointment became effective as of October 16, 1989.
Ms. Weiss’s background includes working on the professional staff of the
U.S. Senate Committee on Finance and experience with the federal
Office of Management and Budget and the federal Medicare system. The
position of director of hospital reimbursement has been vacant since the
resignation of Alan Rosenberg in April 1989.
The New Jersey Department of Health has announced the establishment
of a State Cholesterol Standardization Program. Funds have been
provided by the Department to the Robert Wood Johnson School of
Medicine in New Brunswick to develop and implement a statewide
standardization program. The purpose of the program is to help the
state’s licensed clinical laboratories meet the National Institute of
Health’s recommended levels of precision and accuracy reporting
cholesterol test results. All licensed clinical laboratories in New Jersey
are invited to participate in the program. One outcome of the program
will be the publishing of a directory of the standardization laboratories
by the New Jersey affiliate of the American Heart Association and the
Robert Wood Johnson School of Medicine. Interested parties should
contact the Department of Health for more information.
The Health Care Administration Board (HCAB) adopted the Depart-
ment of Health’s amendments to the Uncompensated Care Credit and
Collection Regulations, with some modifications, at its November 9
meeting. The dollar threshold for compliance was raised from $150 to
$200 and the requirement of using a two-color envelope was removed.
The language of the regulation was changed to remove the requirement
of deferring medical services. However, if hospitals cannot obtain com-
plete information from the patient, they must document why the infor-
mation was not obtained.
The Department indicated that it will develop flexible audit guidelines.
The audit guidelines must be presented to the Hospital Rate-Setting
UNCOMPENSATED
CARE REGULATION
APPROVED
CHOLESTEROL
STANDARDIZATION
PROGRAM
VOL. 87— NUMBER 1 JANUARY 1990
11
MSNJ NEWSLETTER
Commission for final approval. The HCAB also requested the Depart-
ment to provide a cost/benefit analysis of the new Uncompensated Care
Credit and Collection Regulations.
HOSPITAL
PROFILES
REQUIRED BY HRSC
The Hospital Rate-Setting Commission (HRSC) has notified all hospi-
tals that an updated hospital profile must be submitted before action
will be taken on a hospital’s schedule of rates. The profile includes
historical information through 1988 on statistical items such as ad-
missions, patient days, payer mix, uncompensated care, charity care,
same-day surgery cases, and other outpatient data.
HRSC sends a copy of the hospital’s most current profile to the hospital
when a meeting date has been assigned and requests the hospital to
review the data and correct and update it as necessary.
NURSING
The Department of Health has completed its review of 71 hospital
AWARDS proposals for the nursing incentive reimbursement awards. The Depart-
ment awarded a total of $7.1 million to 23 hospitals. Awards ranged from
$126,000 to $500,000 for individual hospitals. Areas in the approved
proposals included management computers, bedside computers, staff
training, other equipment, and organizational restructuring. The De-
partment will recommend 1990 rate increases for the 23 hospitals to the
Hospital Rate-Setting Commission. The Department also will rec-
ommend a monitoring and evaluation component to assure that funds
are spent in accordance with the approved proposals. Department staff
will be involved in the monitoring activities.
GME
LIABILITY
The final published Medicare regulations on medical education pro-
grams cite that the Medicare program is due approximately $440 million
in overpayments. Until now, the medical education methodology reim-
bursed hospitals for all residency programs based on reasonable costs.
Now, a hospital will be reimbursed for allowable medical education costs
divided by the number of interns and residents, which then will be
multiplied by the weighted average number of FTE residents during the
period and adjusted for inflation by using the consumer price index in
each consecutive year after the base period. The base period utilized will
begin on or after October 1, 1983, and end before October 1, 1984.
The new methodology will have a substantial impact on teaching hospi-
tals since the cost received under the previous methodology has long been
spent. In addition, many hospitals will have to revise their 1990 budgets
to reflect the change. It is anticipated that more than 50 percent of the
hospitals effected will be filing an initial appeal challenging the constitu-
tionality of the retroactive rule. Once the liability has been determined
by Medicare intermediaries, hospitals will have 180 days to appeal the
decision or pay their liability.
SUMMER
RESEARCH
FELLOWSHIP
The M. Louise Carpenter Gloeckner, MD, Summer Research Fellowship
Award Committee of the Archives and Special Collections on Women
in Medicine, The Medical College of Pennsylvania, is accepting appli-
cations for summer 1990 research using materials in the Archives and
Special Collections at the College. The Archives houses the business and
academic records of The Medical College of Pennsylvania dating from
its founding in 1850 as the Female Medical College of Pennsylvania. Two
grants of up to $1,500 each for four to six weeks of research in the
Archives will be made to applicants selected by the Award Committee.
For an application and description of the Fellowship, contact the
Archives and Special Collections on Women in Medicine, The Medical
College of Pennsylvania, 3300 Henry Avenue, Philadelphia, PA 19129.
12
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
MEDICARE HMOs
HURT BY SKILLED
NURSING FACILITIES
HCFA and Medicare HMOs are at odds over a rule that clarified when
skilled nursing facilities (SNF) could accept patients. As a result of the
April 1988 clarification, beneficiaries have used skilled nursing care and
HMOs have incurred costs that were not anticipated. Since HCFA pay-
ments to Medicare HMOs for SNF coverage are on a prospective flat
rate based on expected costs for a year, HMOs have incurred substantial
losses that they have not been able to recover from HCFA. This rule
is expected to impact 131 Medicare HMOs in 35 states with plans in
California, Florida, and Minnesota expected to suffer the greatest losses.
In Minnesota, SNF costs incurred by HMOs have increased by 400 to
700 percent.
INDIRECT MEDICAL
EDUCATION
The Prospective Payment Assessment Commission has released data
accumulated during the fourth year of the Medicare Prospective Pay-
ADJUSTMENT men^ System (PPS) that estimates the indirect medical education (IME)
factor at 3.5 percent. The Commission’s previous estimate was 4.4 per-
cent. ProPAC attributed the decrease in the IME factor to the increased
sensitivity of DRGs to the severity of illness as a result of refinements
to PPS. ProPAC has urged Congress to adjust the IME factor for 1990
to 6.6 percent from its current 7.7 percent level. The Senate 1990 rec-
onciliation package would reduce the indirect medical education add-
on to 7.1 percent, while the House has recommended no change in the
factor.
ATTRACTING AND
RETAINING
PHYSICIANS
A subcommittee of the House Committee on Veterans’ Affairs has
charged the Department of Veterans’ Affairs with serious deficiencies in
salary levels, research opportunities, and work environment in its efforts
to recruit and retain physicians. The subcommittee also charged the
Department with failure to adjust salaries to reward long-term service.
The subcommittee concluded that the deficiencies can be remedied and
recommended using bonus pay incentives as a way for recruiting and
retaining physicians from specialties experiencing acute labor shortages.
SUPPLEMENTARY
MEDICAL INSURANCE
PREMIUMS
Monthly premiums for enrollees, age 65 and over, in the Medicare Sup-
plementary Medical Insurance (SMI) Program for calendar year 1990
will be $29 compared to the 1989 monthly premium of $27.90. Monthly
premiums for disabled enrollees in the SMI Program will increase from
$34.30 in 1989 to $44.10 in 1990.
HCFA
ADMINISTRATOR
DECISION
The HCFA administrator has upheld a Provider Reimbursement Review
Board decision that found a hospital operating a 46-bed facility that
closed and subsequently opened as a new 120-bed facility was not enti-
tled to be classified as a new hospital under the Medicare Prospective
Payment System (PPS). The administrator noted that the provider did
not file separate cost reports for the old and new facilities, carried over
its old provider number, and failed to request status as a new hospital
until well after its first year of PPS had ended.
GRAMM-RUDMAN
TRIGGERED
As a result of the Senate not being able to get the budget finalized in
time, the Gramm-Rudman balanced budget law went into effect on
October 16, 1989. Medicare payments to hospitals, doctors, and other
providers will drop approximately 2.1 percent. The payment reduction
will apply to community and migrant facilities, Indian health facilities,
and veteran medical care.
PHYSICIAN CARE A new quality-assurance program is being tested by Private Healthcare
MONITORED Systems, a Massachusetts-based preferred provider organization (PPO)
VOL. 87— NUMBER 1 JANUARY 1990
13
owned by 17 insurance companies. Using data furnished by physicians,
patients, and insurers, the program will review physicians’ care by 13
different quality screens that identify frequent hospital readmissions and
the use of outdated procedures. Private Healthcare Systems operates 40
individual PPO networks in 26 states, and has approximately 1.1 million
enrollees and 30,000 participating physicians.
INVESTEGATIONAL
NEW DRUG
TREATMENTS
Princeton Biomedical Research is conducting studies that may be of
interest to the patients of Medical Society members. These are investiga-
tional new drug treatments for depression, anxiety, age-associated mem-
ory difficulties, and Alzheimer’s disease. The memory testing, available
in ten sites nationwide, involves state of the art computerized testing
simulating real-life situations. The programs are free to qualifying indi-
viduals. For further information, contact Dr. Apter at 609/921-3555.
NEW POSITION
FOR LANCIANO
Ralph C. Lanciano, Jr, DO, of Haddonfield,
was appointed chairman of the Eye Section f
of the Camden County Medical Society. He
also was appointed to the Board of Governors
of the New Jersey Academy of Ophthal-
mology. Dr. Lanciano is a clinical assistant j Ml
professor at the University of Pennsylvania’s \ jMs X
Department of Ophthalmology, Scheie Eye B'*r - ,»
Institute. In addition, he serves as a clinical Jl
associate professor at UMDNJ-School of Os- Jw
teopathic Medicine. Dr. Lanciano is a section head at Kennedy Me-
morial Hospital University Medical Center, Stratford Division, and is
attending ophthalmologist for the New Jersey State Police.
CHILDHOOD
ITP
INVESTIGATION
The New Jersey Pediatric Hematology/Oncology Network (NJPHON)
is conducting a study to compare the efficacy of treatment modality,
total monetary cost differential, emotional cost differential, and
lymphocyte function differences in children with newly diagnosed acute
ITP (idiopathic thrombocytopenic purpura). Children eligible for study
will be prospectively randomized to steroid treatment versus in-
travenous gammaglobulin (IVIG) versus (in select cases) observation
alone. Total costs (financial and emotional) will be assessed at varying
times via questionnaire. Lymphocyte function tests will be performed
four times during the first six months of treatment/observation. The cost
of the IVIG and lymphocyte function testing is being underwritten by
a grant; call NJPHON for more information.
HEALTH
RESEARCH
FELLOWSHIPS
The Advanced Research Fellowship Program is sponsored by the Gov-
ernor’s Council on the Prevention of Mental Retardation and De-
velopmental Disabilities. Each fellow will receive $25,000 a year and the
award is renewable for one year. Applications are due February 2, 1990.
The purpose of the program is to encourage researchers in their efforts
to learn more about the causes of mental retardation and developmental
disabilities. Candidates must have been awarded a PhD or MD to be
qualified for consideration. Candidates also must document their accep-
tance for postdoctoral training under the supervision of an appropriate
mentor at a nonprofit research institution in New Jersey. For infor-
mation, call the Office for Prevention of Mental Retardation and De-
velopmental Disabilities at 609/984-3351 or write to Dr. Deborah Cohen,
Director, Office for Prevention of MR/DD, CN 700, 222 South Warren
Street, Trenton, NJ 08625.
FINI
“Appreciating what you have instead of being miserable about what you
don’t have, is so difficult for the human mind to comprehend.”
14
NEW JERSEY MEDICINE
PRESIDENT’S
PAGE
POLITICAL
EFFECTIVENESS
COMMUNICATING.
SELECTING ISSUES
AND NARROWING FOCUS.
DEALING ACTIVELY,
VIGOROUSLY,
AND HONESTLY.
BEING FIRM,
YET FLEXIBLE.
NEVER MAKING
ENEMIES.
In the November issue of NEW JERSEY MEDICINE, I wrote about
political action and its importance in our program of political effective-
ness— effectiveness in dealing with health policy and public policy that
impacts upon our profession and our patients. I appreciate the
enthusiastic comments and support this article generated. However,
“political action” is but one phase in our coordinated program of politi-
cal effectiveness. Other activities include the following:
We have an ongoing program of discussion with our legislative leaders.
We do not approach our legislators only when we have a problem or a
request. We discuss our priorities, and our perceptions of the health
needs of New Jersey. And, we listen to their perceptions, their ideas,
and their advice as to what is politically practical.
We will not be effective if we try to deal with the hundreds of bills
peripherally affecting our profession, in any given legislative session. We
always are able to identify the major general issues that require our
focus, attention, and major efforts. We will not ignore other or peripheral
issues, but we will not forget our major objectives.
Our major issues require the efforts of the leadership of MSNJ, our
lobbyists, and our key contacts. These efforts are coordinated through
the MSNJ office, for maximum effectiveness. Our discussions with legis-
lators must be strong, but never less than completely honest if we are
to maintain our credibility.
We will take an unyielding stand on essential issues. But, we also under-
stand the political process, and the need to participate in the process
of negotiation that often occurs as legislation is formed. We are not
willing to stand aside from this. This process can make the “inevitable”
a little less onerous; and can help us to achieve at least part of the
“impossible.”
We work hard at achieving generally good relationships with as many
legislators as possible. This does not mean that they will do our bidding;
it usually means, however, that our point of view will be heard and
considered. There is a pattern of shifting alliances with virtually every
bill. No single legislator supports us on every issue. Similarly, there is
no legislator in New Jersey who opposes us on every issue. We cannot
afford to designate as an “enemy” a legislator who opposes us on an
important issue; that legislator’s vote may be the one that we need on
a subsequent issue. Every senator and assemblyman is likely to oppose
us some of the time, and occasionally be an adversary; we always seek
the opportunity to continue our conversations with these legislators, and
to hope that they will be our proponents on a subsequent issue.
This is our program. We follow these steps, and maintain a coordinated
program, always remembering our major goals, and the need to be
working toward these goals on a daily basis. □
VOL. 87— NUMBER 1 JANUARY 1990
17
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1-800-242-GIVE
LEVOXINE® (Levothyroxine Sodium Tablets, USP) For oral administration
The following is a brief summary. Before prescribing, please consult package insert
INDICATIONS AND USAGE:
LEVOXINE (L-thyroxine) tablets are indicated as replacement or supplemental therapy
for diminished or absent thyroid function, resulting from functional deficiency, primary
atrophy, from partial or complete absence of the gland or from the effects of surgery,
radiation or antithyroid agents. Therapy must be maintained continuously to control the
symptoms of hypothyroidism.
CONTRAINDICATIONS:
L-thyroxine therapy is contraindicated in thyrotoxicosis, acute myocardial infarction
and uncorrected adrenal insufficiency.
WARNINGS:
Drugs with thyroid hormone activity, alone or together with other therapeutic agents have
been used for the treatment of obesity. In euthyroid patients doses within the range of daily
hormonal requirements are ineffective for weight reductioa Larger doses may produce
serious or even life-threatening manifestations of toxicity, particularly when given in as-
sociation with sympathomimetic amines such as those used for anorectic effects
PRECAUTIONS:
Caution must be exercised in the administration of this drug to patients with cardiovas-
cular disease. Development of chest pains or other aggravation of the cardiovascular dis-
ease requires a reduction of dosage
Patients on thyroid preparations and parents of children on thyroid therapy should be
informed that replacement therapy is to be taken essentially for life They should im-
mediately report during the course of therapy any signs or symptoms of thyroid hormone
toxicity, eg, chest pains, increased pulse rate, palpitations, excessive sweating, heat
intolerance, nervousness, or any other unusual event In case of concomitant diabetes
mellitus the daily dosage of antidiabetic medication may need readjustment In case of
concomitant oral anticoagulant therapy, the prothrombin time should be measured fre-
quently to determine if the dosage of oral anticoagulants is to be readjusted.
Partial loss of hair may be experienced by children in the first few months of thyroid
therapy, but this is usually a transient phenomenon and later recovery is usually the
rule
Drug Interactions — In patients with diabetes mellitus addition of thyroid hormone
therapy may cause an increase in the required dosage of insulin or oral hypoglycemic
agents
Patients stabilized on oral anticoagulants who are found to require thyroid replace
ment therapy should be watched very closely when therapy is started.
Cholestyramine binds both T4 and T3 in the intestine, thus impairing absorption of
these thyroid hormones Four to five hours should elapse between administration of
cholestyramine and thyroid hormones
Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients without a
functioning thyroid gland who are on thyroid replacement therapy may need to increase
their thyroid dose if estrogens or estrogen-containing oral contraceptives are given.
Drug/ Laboratory Test Interactions — The following drugs or moieties are known to inter-
fere with laboratory tests performed on patients taking thyroid hormone: androgens cor-
ticosteroids estrogens oral contraceptives containing estrogens iodine-containing
preparations and the numerous preparations containing salicylates
Carcinogenesis, Mutagenesis And Impairment ol Fertility — A reported apparent as-
sociation between prolonged thyroid therapy and breast cancer has not been confirmed.
No confirmatory long-term studies in animals have been performed to evaluate car-
cinogenic potential, mutagenicity, or impairment of fertility in either males or females
Pregnancy-Category A— The clinical experience to date does not indicate any adverse
effect on fetuses when thyroid hormones are administered to pregnant women
Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human milk
Thyroid is not associated with serious adverse reactions and does not have a known
tumorigenic potential. However, caution should be exercised when thyroid is adminis-
tered to a nursing womaa
Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Routine
determinations of serum (T4) and/or TSH is strongly advised in neonates in view of the
deleterious effects of thyroid deficiency on growth and development
ADVERSE REACTIONS:
Adverse reactions are due to overdosage and are those of induced hyperthyroidism.
OVERDOSAGE — Excessive dosage of thyroid medication may result in symptoms of
hyperthyroidism, which may not appear for one to three weeks after the dosage regimen
is begun. The most common signs and symptoms of overdosage are weight loss, palpita-
tion, nervousness diarrhea or abdominal cramps sweating tachycardia cardiac arrhy-
thmias angina pectoris tremors headache insomnia intolerance to heat and fever. If
symptoms of overdosage appear, discontinue medication for several days and reinstitute
treatment at a lower dosage level
Complications as a result of the induced hypermetabolic state may include cardiac
failure and death due to arrhythmia or failure
Dosage should be reduced or therapy temporarily discontinued if signs and symptoms
of overdosage appear.
Treatment of acute massive thyroid hormone overdosage is aimed at reducing gas-
trointestinal absorption of the drugs and counteracting central and peripheral effects,
mainly those of increased sympathetic activity. Measures to control fever, hypoglycemia, or
fluid loss should be instituted if needed.
DOSAGE FORMS AVAILABLE:
LEVOXINE (L-thyroxine) tablets are supplied as oval, color coded, potency marked
tablets in 11 strengths: 12 Vi meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - orange,
50 meg (0.05 mg) - white, 75 meg (0.075 mg) - purple 100 meg (0.1 mg) -yellow, 112 meg
(0.112 mg) - rose 125 meg (0.125 mg) - brown, 150 meg (0.15 mg) - blue, 175 meg
(0.175 mg) -turquoise, 200 meg (0.2 mg) -pink and 300 meg (0.3 mg) - green in bottles of
100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg and
500 meg injectable (see injectable package insert).
18
NEW JERSEY MEDICINE
A NEW
BROOM?
EDITOR’S
DESK
Dr. Burton J. Lee III, personal friend of George Bush, now is the phy-
sician to the president of the United States. In that role, he has the
potential to influence greatly the health care delivery system in the
nation and to change markedly the patient-physician-hospital rela-
tionships.
An interview of Dr. Lee by Dennis L. Breo in the November 17, 1989,
issue of the Journal of the American Medical Association is an eye-
opener and deserves your careful reading.
Dr. Lee, who spent all his professional life in a salaried position at
Memorial Sloan-Kettering Cancer Center in New York City, has made
it clear that he intends to expand the activities of the White House
physician “so that when I leave here eight years from now — it is one
of the premier health policy positions in the nation.”
He believes that medical resources should be rationed, that “some phy-
sicians tend” to overtreat the patient and to overdo procedures. “We’re
never going to get a handle on medical costs unless we take the piecework
out of medicine, especially the procedures performed in the surgical sub-
specialties.” “It’s a tremendous conflict of interest for a surgeon’s income
to depend upon how many procedures he does.” “Of course, I can’t say
that I am for putting all physicians on salary, but if I were the president
or the chairman of a House or Senate subcomxiiittee on health, I’d have
to look at it, sure.”
Somehow this anticapitalistic, socialistic approach brings to mind a
debate reported years ago about the virtues of fee-for-service medicine
versus the salaried type. Dr. Francis D. Moore of Boston espoused the
first point of view and Dr. George Crile, Jr, of Cleveland espoused the
latter point of view. Both were eloquent in presenting their arguments,
no blood was spilled and no clear-cut decision was reached, but both
agreed that members of the most-honored profession could be relied on,
by-and-large, to do the right thing. It is most unfortunate that Dr. Lee
feels otherwise.
Perhaps Dr. Lee, unknowingly — to be kind — is refueling the town-gown
conflagration that should have fizzled out years ago. Today, even the
family doctor is residency trained. Would he have this caring physician
relegated to triage? Would he have the patient shipped to a specialty
hospital away from the family and community support he cherishes?
(The recent failure of the Oral Roberts Medical School and Hospital
occurred, at least in part, because patients’ strong desires to be treated
at home were not recognized.)
Is the LMD again to become the object of derision and snide comment?
Are community hospitals worthless? Should all rural hospitals be closed?
An entire career spent on salary in a medical center is not exactly
comparable to being in the trenches, no matter how caring the hospital-
based physician. Memorial Sloan-Kettering Cancer Center is a magnifi-
VOL. 87— NUMBER 1 JANUARY 1990
21
EDITOR’S DESK
cent institution, brilliantly staffed and buttressed by support systems
that are the envy of most other centers. Medicine cannot be practiced
only at that level, now or in the foreseeable future. We would surely
bankrupt the country if we tried.
So please, Dr. Lee, temper your experiences with the evaluations of
others. Those of us who belong to “organized medicine” do have our
patients’ interests first and foremost, but hope that changes will not
make sacrificial lambs of well-meaning physicians. Even your erstwhile
colleague, Dr. Murray Brennan, chairman of the Department of Surgery
at Memorial Sloan-Kettering Cancer Center said, “The requirements of
bureaucracy — filling out paperwork — are demoralizing. Even worse, it
makes it impossible to do what we should be doing — spending more time
with the patient, instead of defensive paper management.” In your
review of health care costs, try to remember Henry Clay’s advice,
“Statistics are no substitute for judgment.” And if you feel that taking
care of your patients took “a lot out of you,” visualize how many of us
are suffering and struggling without the support system you enjoyed,
especially those that took a large part of bureaucracy off your back. If
only the rest of us could be so lucky. □
JOURNAL With the tremendous increase in research being performed in New Jer-
ARTICLES sey, the Committee on Publication voted to increase the documentation
on research published in NEW JERSEY MEDICINE. Beginning with
this issue of our journal, all articles will include the date the article
was received and the date of acceptance by NEW JERSEY MEDICINE.
The Committee believes this policy will give authors more appropriate
credit for their original research and provide for timeliness of reporting
of the work being done in New Jersey.
LETTERS TO Letters to the editor are welcome. Communications should be sent to
THE EDITOR NEW JERSEY MEDICINE, MSNJ, Two Princess Road, Lawrenceville,
NJ 08648.
22
NEW JERSEY MEDICINE
BOOK
REVIEWS
ATLAS OF Marcos V. Goycoolea, MD. W. B. Saunders Company. This extremely
OTOLOGIC SURGERY well-written book is an atlas of otologic surgery. The text graphically
displays the usual surgical procedures performed in otology. The draw-
ings and pictures are absolutely superb and the descriptions are excel-
lent. This atlas, obviously, belongs on the shelf of every otolaryngologist.
But, more than that, any medical student interested in ear surgery would
find the text a great help in understanding the procedures of this special-
ty. This book can be utilized by anyone wanting a fuller understanding
of ear surgery. It is a superb atlas. □ Harold Arlen, MD
I EMERGENCY MEDICINE. George R. Schwartz, MD, Nicholas Bircher, MD, Barbara K. Hanke,
THE ESSENTIAL UPDATE MD, et al. Philadelphia, PA, W.B. Saunders Company, 1989. Over the
years, I have written a number of book reviews, in part to keep up with
newly published material. Frequently, however, the books I have re-
viewed have not been strikingly relevant, but Emergency Medicine. The
Essential Update is an exception; it is more than a textbook.
By their nature, medical textbooks cannot remain on the cutting edge
of advances. This is a problem in the area of emergency and acute care
medicine where change happens quickly and across a broad spectrum
of medical specialties. This book accomplishes what it promises to do —
namely, to provide a “cutting-edge” update that can supplement any
textbook of emergency medicine as well as textbooks of internal medi-
cine, surgery, and family practice. In fact, it does offer essential and
focused information which can be lifesaving. Since I am a practicing
emergency physician, I have found this book to contain concise, relevant,
and practical information to assist me in the care of my patients. The
fact that it is not a weighty, medical tome means the reader is able to
digest more of its information than a typical medical textbook.
It is a pure coincidence that I personally know two of the six editors
of this fine book. I have not had conversations with either one of them
about this matter. They have not asked me to speak kindly of their book.
Nonetheless, the book deserves to be spoken about in a kind fashion and,
more importantly, the book deserves to be in the library of every practic-
ing emergency physician. □ James E. George, MD, JD
SOCIAL SIGNIFICANCE Barry D. McPherson, PhD, James E. Curtis, MA, John W. Loy, PhD.
Qp SPORT Champaign, IL, Human Kinetics Books, 1989. This book is a textbook
for psychology students; yet it makes very interesting reading for anyone
who has more than a passing interest in sports. The authors discuss a
variety of topics dealing with the social, economic, political, and legal
aspects of sports, and how these various entities react with each other
and with such other factors such as race relations, women’s liberation,
social interaction, class structure, subcultures, and age-related ac-
tivities. Included in the book is a wealth of historical background ma-
terial relative to the previously mentioned topics and, hence, the book
is a valuable reference in this regard. I recommend it as a book to read
for those concerned about sports medicine or for those physicians with
an interest just in sports per se. □ Christine E. Haycock, MD
VOL. 87— NUMBER 1 JANUARY 1990
25
When it comes to your
patients^ health
leave no stone unturned.
lithotripsy at
The New Jersey Kidney Stone Treatment Center can be the alternative.
Convenient ce-The New Jersey Kidney Stone Treatment Center is centrally located in downtown
New Brunswick, near major highways, for easy access for you and your patients.
Flexible scheduling -The Center offers scheduling with no delay. In most cases, your patient can be
treated within a week-of your call. Our extended hours allow you to make appointments at the
convenience of both you and your patients.
Bath-free equipment- The Center is equipped with the most advanced Dornier HM4 lithotripter,
eliminating the need for a water bath, allowing for easier patient handling and greater patient comfort.
Also in use is a state-of-the-art Shimazdu Hydrojust III cystoscopy table.
Experienced, professional staff- The staff of the New Jersey Kidney Stone Treatment Center is
well-versed in lithotripsy treatment, and includes board-certified Anesthesiologists, critical-care trained
nurses and skilled lithotripsy technicians.
Physician billing -Urologists treating patients at the Center have the advantage of billing their
patients or third-party payers directly through their own offices.
Easy referral system- If desired, physicians can easily refer their patients to one of our staff
Urologists for lithotripsy treatment.
HMO eligibility -The Center has established arrangements with most major area HMO's.
For more information regarding how the Center can help you and your
kidney stone patients, call I -800-542-8887 or (20 1 ) 937-86 1 4.
New Jersey
Kidney
Treatment Center
Located at Robert Wood Johnson University Hospital
New Brunswick, New Jersey 1 -300-542-8887
The New Jersey Kidney Stone Treatment Center is operated by Health Horizons (ESWL), L. P., affiliated with the
following hospitals: Community Memorial Hospital, Freehold Area Hospital, Helene Fuld Medical Center, Jersey
Shore Medical Center, Raritan Bay Medical Center, Riverview Medical Center, Robert Wood Johnson University
Hospital, St. Francis Medical Center, St. Peter's Medical Center, Somerset Medical Center.
26
NEW JERSEY MEDICINE
Medication Errors:
1 977 to 1 988
Experience in Medical Malpractice Claims
SUZANNE L. KUEHM, MPH
MICHAEL
The Risk Prevention Department of the Medi-
cal Inter-Insurance Exchange of New Jersey
(MIIENJ), a physician-owned carrier, was
established on February 1, 1983, by its Board of
Governors. Two of the objectives of the Department
are to decrease patient injury and to reduce medical
malpractice claims with its attendant emotional and
economic stresses. It appears that medication error
is one area where risk prevention efforts could make
a significant contribution towards meeting these
goals. Therefore, it seems beneficial to analyze all
cases where indemnity was paid due to a medication
error.
PROCEDURE
All cases identified previously as having a medi-
cation error as a significant cause of the suit and
closed with a payment to the plaintiff during the
period of February 1, 1977, through December 31,
1988, were reviewed. There was a total of 337 files
reviewed, inclusive of all specialties. In 57 percent
of these files, medication error was the primary
cause of the suit and, in the remaining files, it was
an important factor. Total indemnity paid was
$30,144,636, an average of $89,450 per file. Thirty-
four distinct performance errors were identified, and
Ms. Kuehm is a loss analyst, Risk Prevention Depart-
ment, Medical Inter-Insurance Exchange of New Jersey
(MIIENJ), and Dr. Doyle is chairman of the claims com-
mittee of MIIENJ and a member of the Board of Under-
writers. Requests for reprints may be addressed to Dr.
Doyle, MIIENJ, Two Princess Road, Lawrenceville, NJ
I 08648.
. DOYLE, MD
there were between one and five of these per-
formance errors in each of the 337 files analyzed.
Only those actions which indicate a trend are re-
ported here. The actions are organized into nine
categories: allergic reaction; error in writing the
prescription; communication failure; administration
of excessive dose of medication; prescription of con-
traindicated medication; failure to monitor drugs for
toxic levels; treatment with antibiotics; prescription
of medication to treat symptoms; and generic drugs.
TRENDS
A. Allergic Reaction (indemnity paid,
$1,063,657). There were 34 files involving allergic
reactions. These cases resulted in six deaths, one
profoundly brain-damaged patient (permanent
coma), and 14 anaphylactic reactions with elec-
trocardiogram (EKG) changes, hypotension, respir-
atory difficulty, cyanosis, and facial edema resulting
in hospitalization. In 5 files, the extent of the reac-
tion was not specified, and the reactions in the re-
maining files consisted of gastrointestinal hemor-
rhage, cellulitis, and conjunctivitis. The deaths were
due to the administration of penicillin (4 files), am-
picillin (1 file), and ibuprofen (Motrin®) (1 file).
Sodium thiopental (Pentothal®) was the cause of the
severe brain damage in 1 file. Of all the allergic
reactions, 16 were due to an allergy to penicillin and
the administration of ampicillin (5 files), penicillin
(6 files), bacampicillin hydrochloride (Spectrobid®)
(2 files), oxicillin (1 file), amoxicillin (1 file), and
ampicillin trihydrate (Principen®) (1 file). In 5 files,
there was an allergy to acetylsalicylic acid (aspirin),
and the physicians prescribed ibuprofen (Motrin®),
VOL. 87— NUMBER 1 JANUARY 1990
27
ascriptin, Darvon® compound, and Percodan®. The
latter three drugs all contain acetylsalicylic acid
(aspirin), and ibuprofen (Motrin®) is contrain-
dicated for persons who have a history of allergy to
acetylsalicylic acid (aspirin). In each of these
events there was an indicator that should have
alerted the physician against prescribing the drug.
The following are examples.
1. The specific allergy was noted in the patient’s
office record or hospital chart, but the insured either
never reviewed the office chart before prescribing the
medication; admitted to overlooking the entry in the
record; or failed to read the discharge summary of
a previous hospitalization.
Example: A patient gave a history of an allergy
to penicillin. The physician prescribed ampicillin.
The patient developed a rash and difficulty in
breathing requiring hospitalization. This was the
second time this patient required hospitalization for
an allergic reaction to ampicillin.
2. Some physicians stated that they were not
“told forcefully enough, so the information didn’t
stick.” Other physicians admitted that they had not
questioned the patient regarding allergies. There
also were some instances when a pharmacist had
called to notify the physician that the patient was
allergic to the prescribed medication and was told
by the physician to “give the drug anyway,” believ-
ing that it was still the best choice for the condition.
Example: A patient gave a history of allergy to
penicillin. The same patient was given intravenous
oxicillin preoperatively after induction, but before
an incision was made. The patient developed a rash
on the face and extremities, hypotension, and EKG
Medication Errors by Specialty. The named specialty within each sphere had the greatest number of suits
within the specific error category (February 1, 1977, to December 31, 1988).
28
NEW JERSEY MEDICINE
changes indicative of cardiac ischemia which
necessitated aborting the procedure.
Example: A patient related that his father died
from a reaction to sodium thiopental (Pentothal®).
The patient was given sodium thiopental (Pen-
tothal®) and, subsequently, developed a laryngo-
spasm resulting in anoxic brain damage and per-
manent coma.
3. Office staff also have been responsible for pa-
tient injuries.
Example: The insured ordered a computed axial
tomographic (CAT) scan and wrote “no dye” be-
cause of the patient’s history of allergy to iodine. In
addition, the patient verbally told the receptionist
the same warning. The receptionist filled out the
request form incorrectly, stating “use dye.” The
radiologist never saw the original request. The pa-
tient suffered anaphylactic shock requiring emer-
gency hospital treatment with oxygen and in-
travenous steroids.
Example: An office staff member recopied patient
information from part 1 to part 2 of a patient’s chart
and neglected to write down the patient’s allergies
on the second part.
4. There also is some indication that allergic reac-
tions occurred because the insureds were not aware
of the drug components of the medication or the
drug manufacturers’ warnings associated with the
medication.
Example: The patient gave a history of previous
allergic reaction to acetylsalicylic acid (aspirin). The
insured prescribed ibuprofen (Motrin®). The patient
developed an anaphylactic reaction with cardiopul-
monary arrest, resulting in coma and death. Phy-
sicians’ Desk Reference states, “Do not prescribe for
patients who have a known sensitivity to
acetylsalicylic acid (aspirin).”
★ Allergic reactions to prescribed medications
have caused patient deaths and morbidity. In an
effort to reduce the incidence of these claims and
subsequent damages:
1. Do heed patient warnings of known or
suspected allergies.
2. Indicate all allergies in bold lettering in the
patient record. Ideally, this should be in the front
of the chart where it will not be overlooked easily.
3. Question the patient regarding allergy to medi-
cations including over-the-counter (OTC) medi-
cations. If this is not possible, consult previous hos-
pital records or prior treating physicians.
4. Be aware of the composition of drugs before
prescribing medication.
5. Educate the office staff regarding the impor-
tance of allergy notations on charts and forms.
6. Radiologists should insist on seeing the original
request for diagnostic imaging, especially when dye
could be used.
7. If there is a need to prescribe a drug to which
a patient is allergic, such as an antibiotic which
would be life saving, consult first with a board
certified allergist.
B. Error in Writing the Prescription (indemni-
ty paid, $419,111). While this “error” did not appear
frequently (six files), the damages and the potential
for damage were great. It also is an error which easily
is preventable and, therefore, merits inclusion. The
following are examples from these files.
Example: A pediatrician wrote a prescription for
phenytoin suspension (Dilantin® Suspension) taking
into consideration the patient’s age, weight, and
serum phenytoin level. The insured did not specify
pediatric suspension. The prescription was filled
with adult-strength phenytoin (Dilantin®), which is
greater than four times the pediatric stength.
(Dilantin® Pediatric provides 30 mg of medication
in 5 ml dose; adult strength, in contrast, contains
125 mg in 5 ml.)
Example: A 20-year-old with leukemia was hospi-
talized for induction chemotherapy and discharged
to continue consolidation treatment with cytarabine
(Cytosar-U®) at home. The pharmacist filled the
prescription with cyclophosphamide (Cytoxan®).
The patient took this drug for five days. This took
the patient out of remission, and she died two
months later. The pharmacist paid 3/4 of the indem-
nity, the insured paid 1/4 of the indemnity.
Example: A patient hospitalized for atrial
fibrillation was discharged with a prescription for
digoxin (Lanoxin®). The patient returned 24 hours
later in digoxin toxicity. The physician had intended
to prescribe 0.25 mg od but had written “4 tabs per
day.” Two tablets (0.125 mg per tablet) per day
would have equaled 0.25 mg.
Example: An office nurse administered an injec-
tion of lorazepam 10 mg (Ativan®) instead of
lorazepam 1 mg (Ativan®). The office nurse read the
1.0 mg as 10 mg.
★ It does not take long to recognize errors such
as these can occur easily with both written and ver-
bal orders. A few simple guidelines should help to
minimize the chances of these errors occurring:
1. Never place a zero after a decimal; at times,
the decimal may not be seen. (The U.S. Pharma-
copea has requested drug companies to follow this
guide in their labelling.)
2. Always use a zero before a decimal; decimals
get lost on lines.
3. Use a fraction instead of a decimal between two
numbers.
4. When writing prescriptions be careful of drugs
that look alike, such as adriamycin versus acromycin
or Cytosar® versus Cytoxin®.
5. Be careful of drugs that sound alike, especially
when giving verbal orders to pharmacists, such as
VOL. 87— NUMBER 1 JANUARY 1990
29
Zantac® or Xanax®; and seldane or feldene.
6. As a safeguard against misinterpretation of
both written and verbal prescriptions include the
diagnosis or the reason for the drug for wheezing;
give the strength 500 mg not two tablets of the dose;
include directions for taking medication; and re-
quest the pharmacist to place warnings on the label.
(These suggestions were made by Michael R.
Cohen, MS, RPh, clinical assistant professor, School
of Pharmacy, Temple University, and assistant edi-
tor of Hospital Pharmacy.)
C. Communication Failure (indemnity paid,
$1,215,878). There were 19 files where patient in-
juries occurred (including three deaths and one inci-
dent of loss of sight) as a direct consequence of the
physicians: failing to communicate to another phy-
sician; failing to review the chart; failing to com-
municate effectively with a pharmacist; failing to
communicate clearly with office staff; and failing to
communicate effectively with an answering service.
The following examples elaborate these points.
Example: During a presurgical interview, an
anesthesiologist learned the patient had hepatitis
several years earlier and decided, because of this, the
patient should receive a narcotic anesthesia. A sec-
ond anesthesiologist failed to read the note made by
the interviewing anesthesiologist and gave halothane
without any problems occurring. One week later the
patient again had surgery. The patient again was
given halothane because it was assumed that the
patient was given the narcotic anesthesia previously.
This resulted in the patient’s death due to halothane
hepatitis.
Example: The physician telephoned a prescrip-
tion to the pharmacist for novocolchine (Col-
chicine®). He ordered 1 pill every 15 minutes until
pain subsided, not to exceed 6 to 10 pills in 24 hours.
The pharmacist omitted the limiting number in the
directions for taking the drug. The patient took 35
pills in 24 hours resulting in renal failure and requir-
ing renal dialysis. The pharmacist stated that he was
not advised of the limit by the physician.
Example: A patient was being unsuccessfully
treated with a variety of antibiotics for a post-
operative infection. The physician requested an in-
fectious disease consultation. The requested special-
ist never arrived to see the patient. After a lengthy
hospitalization, the patient was discharged with no
residual effects. A jury, however, faulted the insured
for not following up on obtaining the consultation
since he had documented his need for assistance in
antibiotic management of this patient. The jury
awarded the plaintiff $67,000.
Example: A patient on long-term maintenance
with warfarin sodium (Coumadin®) was notified by
the laboratory to contact his physician regarding his
prothrombin time results. (The test result indicated
the bleeding time was too prolonged.) The patient
telephoned the insured’s office and was told by the
answering service to call back in one week, since the
physician was on vacation. The patient complied,
but by that time he had lost the sight in one eye
due to a vitreous hemorrhage. A physician is respon-
sible for giving sufficient instructions to the
answering service. In this instance, the covering
physician was not given the patient’s telephone
number by the answering service. From the earlier
discussions, it is apparent that communication fail-
ures also resulted in allergic reactions and some er-
roneous prescriptions.
★ Breakdown in communication among pro-
fessionals has caused medication errors which re-
sulted in patient injury and death and led to success-
ful medical malpractice suits. There are files where
medical peer reviewers opined that the physicians
did not deviate from the standard of care, but juries
decided in favor of the plaintiff because they be-
lieved the physician had a duty to followup on a
communication breakdown.
Decreased Awareness of Pharmacokinetics of
Drugs. The broad category of decreased awareness
of pharmacokinetics of drugs is composed of a va-
riety of behaviors, including prescribing a dose of
medication which is: too large; too potent for the
presenting symptoms; a lower dose than required;
administered by an improper route, contraindicated
because of patient history or other concurrently
prescribed medications; not monitored for toxic
levels or adverse reactions; and lacking in proper
instructions for administration. It appears that the
best single explanation for these would be a less than
desirable pharmacological awareness of the drugs
prescribed. There were 152 files in this category. We
will discuss only the most significant of these.
D. Administration of Excessive Dose of Medi-
cation (indemnity paid, $12,350,445). There were
57 files in this category, with 16 deaths, 11 patients
with permanent injury, and 3 patients with brain
injuries. (This category does not include over-
medication due to a failure to monitor blood levels
with resulting toxic levels of a drug being obtained.)
Some case examples representative of these files fol-
low.
Example: A three-year-old child with breathing
difficulty was sedated with meperidine hydro-
chloride (Demerol®), promethazine hydrochloride
(Phenergran®), and chlorpromazine hydrochloride
(Thorazine®) for an electroencephalogram. The
child never aroused. He vomited and aspirated, and
then died. The peer reviewer opined that the dose
was appropriate for a normal child, but not for one
with breathing difficulty.
Example: A patient was treated for arthritis with
high doses of steroids. The patient developed pan-
30
NEW JERSEY MEDICINE
creatitis, gastritis, peritonitis, an abdominal
abscess, and generalized sepsis before dying.
Example: Nine consecutive doses of Mannitol®
were given to a patient prior to undergoing cataract
surgery. The patient developed an electrolyte im-
balance secondary to the Mannitol®, suffered a
cardiac arrest, and died. The peer reviewer and de-
fense expert opined that an inordinate amount of
Mannitol® had been given.
★ Patients received an overdose of medication be-
cause physicians: failed to consider patients’ indi-
vidual requirements at the time of prescribing the
drug, and were unfamiliar with pharmacodynamics
of the drugs prescribed.
E. Prescription of Contraindicated Medication
by Patient’s History or Due to Noncompatability
of Several Prescribed Drugs (indemnity paid,
$5,774,346). There were 51 files in this combined
category. There were 12 patient deaths, and 6 pa-
tients suffered severe brain damage. The majority of
drugs which were contraindicated by patient’s his-
tory were the anti-inflammatory drugs, both steroid
and nonsteroidal, and medications which contain
acetylsalicylic acid (aspirin). Typically, the patient
had a low hemoglobin and hematocrit (that could
be an indicator of active bleeding) or the patient
gave a history of ulcer disease. After taking these
drugs, the patients developed severe gastrointestinal
hemorrhage requiring hospitalization, many trans-
fusions, and sometimes surgery.
Example: A patient gave a history of bleeding
from acetylsalicylic acid (aspirin) ingestion and
having a gastrectomy 15 years earlier. The physician
prescribed naproxen (Naprosyn®), and the patient
developed a near-fatal gastric hemorrhage.
Example: A patient, who already was taking
bronchodilators for asthma, was treated with pin-
dolol (Visken®) for hypertension. This drug, like all
beta-blockers, must be used with extreme caution in
patients who have asthma. This patient died im-
mediately after taking this drug.
In all 51 files, either one or several of the following
behaviors were seen: the physician failed to take a
complete history; the physician ignored the patient’s
complaints associated with taking the medication;
or the physician disregarded the patient’s medical
history.
When the cases involving the prescription of two
noncompatible drugs were analyzed, the drugs that
appeared more than once were Actifed® and the
combination of an anticoagulant with an anti-in-
flammatory medication. Commonly, the physicians
never ascertained the present medications the pa-
tients were taking. For example, an orthopedist
prescribed an anti-inflammatory drug without de-
termining that the patient was taking warfarin so-
dium (Coumadin®), prescribed by an internist.
In some cases, the physician was not familiar with
the pharmacodynamics of the drugs involved. For
example, a patient was taking phenelzine dihydro-
gen sulfate (Nardil®). The patient saw her family
practitioner for complaints of a cold. She relayed
that she had previous reactions from the combina-
tion of other drugs with phenelzine dihydrogen
sulfate (Nardil®). She was reassured that Actifed®
was safe to use with phenelzine dihydrogen sulfate
(Nardil®) which is an monoamine oxidase (MAO)
inhibitor. Within 24 hours after taking Actifed®, she
became comatose and remains dependent upon a
caretaker for activities of daily living. (Sym-
pathomimetics, of which Actifed® is only one exam-
ple, are contraindicated with MAO inhibitors.)
★ It is imperative to thoroughly question patients
regarding all medications they are taking. Also, a
thorough awareness of pharmacodynamics of drugs
prescribed is necessary to insure patient safety, es-
pecially in view of the number of medications many
patients are taking at any one time.
F. Failure To Monitor Drugs for Toxic Levels
or Adverse Reactions (indemnity paid,
$2,036,471). There were 39 files in this category. The
drugs which were found more frequently were gen-
tamicin, warfarin sodium (Coumadin®), heparin so-
dium (Heparin®), the nonsteroidal anti-inflam-
matory group, and the digitalis derivatives. In every
one of these cases, there was a failure or delay to
obtain blood tests to monitor the patient’s response
to the drug. When the patient did offer complaints
indicative of a toxic level or adverse reaction to the
medication, the physician either failed or delayed in
discontinuing the drug or checking the serum level
of the drug. The patient damages were severe: five
deaths, five patients with severe brain damage, and
seven patients with total or severe hearing loss. The
other patients had life-threatening events or
prolonged hospitalization and recovery.
Example: An eight-month-old child was treated
with gentamycin for nine days. No blood tests were
done to monitor serum levels of the drug. The child
is bilaterally deaf, with little chance of speech de-
velopment, because of the age at which the hearing
loss occurred.
Example: Warfarin sodium 25 mg (Coumadin®)
was prescribed for a patient based upon a one-week-
old blood test. The physician ignored the patient’s
complaints of side effects, resulting in a severe
hemorrhage from the esophagus, necessitating many
transfusions.
Example: Five days after being discharged from
the hospital, a patient, who had been taking digoxin,
suffered a cardiac arrest and died. The patient’s
digoxin level was 7; toxicity level is 2.5. During the
patient’s hospitalization, there had been no monitor-
ing of the serum digoxin level.
VOL. 87— NUMBER 1 JANUARY 1990
31
★ There is evidence that it is difficult to defend
a medication error when a patient injury occurs be-
cause the physician failed to follow the manufac-
turer’s recommendation for performing periodic
blood tests to access the serum level of the drug. This
especially is true with gentamycin, warfarin sodium
(Coumadin®), heparin sodium (Heparin®), digitox-
in, and digoxin. It is of equal importance, when
prescribing nonsteroidal anti-inflammatory drugs,
to evaluate periodically the patient for adverse reac-
tions.
G. Treatment with Antibiotics (indemnity
paid, $5,867,802). There were 73 files involving inap-
propriate use of antibiotics. Of the 21 specialties
represented in these 337 files, this performance error
was found in 11 specialties. The actions consisted of
failure to order a culture and sensitivity test; treat-
ment with the wrong antibiotic; failure to re-evalu-
ate when the infection did not respond to the
prescribed antibiotic; failure to prescribe an anti-
biotic; and prescribing a lower dose than required.
In those files where a culture and sensitivity test
was not performed, physicians stated the reasons for
choosing the antibiotics were: “It usually was suc-
cessful before,” or “It is the routine antibiotic used
in these cases.” In each of these 15 files, the bacteria
was not sensitive or was resistant to the prescribed
antibiotic. The patients were treated inappropriate-
ly over a period of time and the majority of them
suffered loss of limbs or digits. In other files, phy-
sicians prescribed antibiotics to treat presumed sys-
temic infections (often by telephone diagnosis)
before obtaining a blood culture. One patient had
meningitis and, because of the wrong antibiotic ther-
apy, suffered severe residual brain damage. In
another example, there was a delay in diagnosing
subacute bacterial endocarditis. Initial blood cul-
tures were negative (false negative) due to prior
long-term and inappropriate antibiotic treatment.
This patient required surgery for mitral valve re-
Table. Additional reference materials for drug information.
• Drug Facts and Comparisons. This text contains
objective drug information to facilitate comparison of
prescription and over-the-counter drugs. The infor-
mation is organized by therapeutic use with groups and
subgroups to facilitate comparison of drugs with similar
uses. One physician reviewer found the section on “pa-
tient information” very desirable. This section reminds
the physician what the patient should be told about the
prescribed drug. This reference contains complete de-
scriptive information on all drugs, regardless of current
marketability (i.e. how long they have been available).
Often PDR does not include detailed descriptions on
older drugs. As drugs become available in generic form,
they may disappear from future editions of PDR. This
reference combines information which is pertinent to the
physician from the drug package insert, current text-
books, and many professional journals. The editorial
panel for Drug Facts and Comparisons consists of rep-
resentatives of medicine and pharmacy from some of the
most respected universities. The hardbound version of
this reference is updated yearly; the looseleaf version is
updated monthly. (Facts and Comparisons, 111 West
Port Plaza, Suite 423, St. Louis, MO 63146-3098.)
• Drug Information for the Health Care Pro-
fessional. Published by the U.S. Pharmacopoeial Con-
vention, Inc., this publication has several advantages: it
is indexed by indications for use for easy reference to
drugs used in the treatment, prevention, or diagnosis of
disease. Along with Drug Facts and Comparisons, it in-
cludes unlabeled accepted uses. Among its organiza-
tional categories there is one, “Precautions To Con-
sider,” which includes drug interactions, diagnostic inter-
ference, and medical problems/contraindications. It in-
cludes a section on patient consultation including
“Before Use,” “Proper Use,” “Precautions,” and
“Side/Adverse Effects— those needing medical attention
and those that do not need medical attention.” The stan-
dards (strength, quality, and purity) for drugs published
in USP are recognized as official by the federal govern-
ment and are enforceable by the FDA.
• Advice for the Patient. USP-DI also publishes this
drug information in lay language. This text contains drug
information prepared specifically for the consumer. It is
sold only to health care professionals as a reference for
the patient which may be placed in the physician’s wait-
ing room. Permission is given to photocopy monographs
for patients if no charge is made to the patient for the /
monographs. Each drug monograph contains proper use I
directions and precautions to be observed among other
topics. Also available are these same monographs print-
ed as single-page leaflets on an assortment of 80 drugs.
These are similar to the AMA Patient Medication Instruc-
tion sheets which use the USP database. Sections in-
clude “Uses of This Medicine,” “Before Using This Medi-
cine,” “Proper Use of This Medicine,” “Precautions While
Using This Medicine,” "Side Effects of This Medicine,”
and “Discontinuing This Medicine.” These now are avail-
able for 83 drugs through USP. (They no longer are to
be ordered from the AMA.) These leaflets would be es-
pecially useful when prescribing such drugs as an-
ticoagulants, diuretics, nonsteroidal anti-inflammatories,
and digitalis preparations. (For more information write:
USP, 12601 Twinbrook Parkway, Rockville, MD 20852.)
• Drug Evaluations. This book is prepared by the
professional staff of the American Medical Association,
Department of Drugs, providing physicians and other
health care professionals with unbiased information on
the clinical use of drugs. It has been published for 20
years and it is updated every 3 years. It is available at
a discounted price as a benefit of membership of the
AMA.
• DUET (Drug Use Education Tool). These are
pamphlets for a variety of drugs published by the Ameri-
can Academy of Family Practice. Available to members,
this is one example of drug information available through
specialty societies.
• Medifile Cards. These are blank cards which allow
physicians to list all medications, including dosage. The
patient carries this card, to be shown to other treating
physicians or emergency personnel. These biank cards
are available from the Medical Society of New Jersey at
no charge.
32
NEW JERSEY MEDICINE
placement and repair of mycotic cerebral aneurysm.
There were 26 files where the wrong antibiotic was
given. There is the possibility that the wrong anti-
biotic may have been given because a culture and
sensitivity test was not done, but this was not stated
in these cases. What specifically was seen in these
files either was a failure to followup on a culture and
sensitivity report after ordered and obtained, or a
failure to order the antibiotic which the culture and
sensitivity report recommended. There were three
patient deaths, one patient with severe brain dam-
age, eight amputations, three cases of chronic os-
teomyelitis, and sterility of two teenage females as
a sequalae to these infections.
There were 26 files where there was a failure to
give antibiotics. In the majority of these files the
patients had come to the emergency room for treat-
ment of a laceration, or were patients with diabetes
mellitus and being treated for foot ulcers or had
incurred postoperative infections. There were six pa-
tient deaths, five above-the-knee amputations, three
amputated fingers, one partial amputation of the
sternum, and five other patients requiring additional
surgeries and facing permanent partial disability.
Example: A 49-year-old patient was discharged
from the hospital following coronary artery bypass
surgery with a prescription for an antibiotic to treat
persistent drainage from the incision. The patient
was monitored by his internist. After five weeks of
antibiotic therapy, there was no change in the con-
dition of the draining incision, and the internist re-
ferred the patient back to the surgeon. The surgeon
discontinued all antibiotics. The patient continued
to be seen by the surgeon monthly for one year. The
drainage from the incision persisted. No antibiotic
was prescribed during this 12-month period. The
patient eventually sought treatment from another
physician who diagnosed osteomyelitis of the ster-
num. A partial sternectomy was performed; in ad-
dition, the patient required intravenous antibiotic
therapy for several weeks.
★ There is additional morbidity and mortality
from infections when physicians neglect to obtain
culture and sensitivity tests from draining wounds
and then fail to treat the infection with the ap-
propriate antibiotic. When an apparent systemic in-
fection is treated with antibiotics before obtaining
a blood culture, the blood culture may yield a false
negative result, leading to a delay in diagnosis and
treatment. There were cases where there was no re-
evaluation when the patient’s infection did not re-
spond to the prescribed antibiotic. Of the total 73
files, there were only 2 files where an infectious dis-
ease specialist had been consulted.
H. Prescription of Medication To Treat Symp-
toms (indemnity paid, $3,397,105). There were 39
files in this category. In the majority of these cases,
physicians prescribed medication to alleviate pa-
tients’ complaints of pain. In each of these cases,
with the symptom of pain absent or diminished
through medication, the physician failed or delayed
in diagnosing the patient’s condition. In many of the
39 files, the prescription of medication masked the
patient’s condition and made the diagnosis more
difficult. In this category, there were 16 patient
deaths, 1 severely brain-damaged patient, and 2 pa-
tients whose future health is threatened. A few ex-
amples are presented for clarification.
Example: A three-month-old hospitalized infant
was treated with acetaminophen (Tylenol®) for a
temperature of 105°C. The physician suspected
meningitis but did not continue with a diagnostic
workup because the infant’s temperature responded
to the acetaminophen (Tylenol®). The physician
thought that the infant was better; however, the
child became worse later the same evening and died.
Example: A 19-year-old was treated with Per-
codan® in an emergency room. He was misdiagnosed
as having gastroenteritis. He actually had acute
myocarditis and pericarditis. The Percodan®
masked his symptoms and he died two days later.
Example: A 35-year-old was treated with
meperidine hydrochloride (Demerol®), hydroxyzine
pamoate (Vistaril®), Combid® spansules, and Don-
natal®. The patient had a ruptured appendix and
peritonitis, but the analgesics had masked the pain
and made the diagnosis more difficult.
★ In an attempt to alleviate patient discomfort,
physicians have increased patient morbidity and
mortality through the practice of prescribing medi-
cation to eradicate symptoms before establishing a
diagnosis. By removing these clues to the patient’s
condition, the physicians found it more difficult to
make a correct and timely diagnosis.
I. Generic Drugs (indemnity paid, $21,000).
The issue of generic drugs is included here not be-
cause it reflects a trend, but to report that the
prescription of generic drugs or the substitution for
generic drugs produced only one claim. There was
only one file involving a generic drug; the following
is a summary of that incident.
A patient being treated for hypertension had a
prescription for hydroflumethiazide (Diucardin®)
filled through a mail-order pharmacy. The phar-
macy erroneously filled the prescription with
bishydroxycoumarin (Dicumarol®), an anticoagu-
lant, labeled as hydroflumethiazide (Diucardin®).
The patient developed retroperitoneal hemorrhage
and required hospitalizations over a period of two
months before the problem was identified. The pa-
tient had notified the physician that the pills did not
look the same as the previous pills. The physician
stated that he had no way of identifying the pills
because they were generic. When the patient men-
VOL. 87— NUMBER 1 JANUARY 1990
33
tioned this a second time, and the physician could
not find a cause for the coagulopathy, the physican
sent a sample of the pills to the pharmaceutical
company for identification. A jury found the insured
10 percent liable ($21,000 of the total $215,000 ver-
dict). An article written in Medical Economics, on
May 25, 1987, entitled “Generics Are Giving Me A
Cheap Headache,” describes a similar situation.
SUMMARY
MIIENJ has paid $30,144,636 in indemnity from
1977 through 1988 for medical malpractice suits aris-
ing from medication errors. A review of these files
revealed that patients incurred death and serious
morbidity, and that several specific behavior errors
accounted for the majority of patient injury. Among
the damages that occurred during that time period
were 88 deaths, 15 patients with profound brain
damage, 15 patients who alleged that they had be-
come addicted to medications prescribed for pain,
10 patients who required amputations of limbs, and
12 patients who suffered some degree of hearing loss
or decreased visual acuity. The predominant
categories where insureds incurred difficulty were in
disregarding patient allergies to specific drugs
(acetylsalicylic acid (aspirin), penicillin and its de-
rivatives); prescribing drugs without consideration
of the patient’s medical history; failing to monitor
therapy with anticoagulants, nonsteroidal anti-in-
flammatory drugs, digitalis derivatives, theophyl-
line, and aminoglycoside antibiotics; antibiotic ther-
apy; and errors in the writing of prescriptions.
In order to reduce the number of patient injuries
and accompanying medical malpractice suits from
medication errors, the following suggestions are of-
fered:
1. Heed the patient’s warning regarding drug
allergies and prescribe a substitute drug, es-
pecially if the drug is aspirin or penicillin (and
derivatives) or if the patient gives a history of
having asthma. If the patient gives a history of
aspirin sensitivity, make certain the drug you are
prescribing does not contain aspirin as one of its
components. Often physicians stated that they were
not aware that aspirin was contained in the drug
they prescribed for patients with a documented al-
lergy to aspirin. Question all patients regarding al-
lergy to the drug you are considering prescribing.
Ask if the patient has ever taken the drug before and
if he/she has had any problems related to taking the
drug.
2. Maintain in the front of the patient’s office
record a current listing of all drugs which the
patient is taking and include the date prescribed,
refill dates, and date the drug was discontinued.
Also, include on this medication sheet drugs other
physicians are prescribing and over-the-counter
drugs the patient admits to taking. Indicate on the
top of this sheet, along with the patient’s name, a
diagnosis, past medical history, and drug allergies.
This may reduce the incidence of prescribing drugs
that are contraindicated by the patient’s history,
prescribing drugs to which the patient is allergic,
and prescribing an excessive amount of tranquil-
izers, hypnotics, and narcotics. It also may prompt
the physician to re-evaluate the effectiveness of a
drug and either consider a different diagnosis or a
different drug.
A stamp, “Blood Test Needed,” could be used to
remind the physician of the need to monitor such
drugs as diuretics, anticoagulants, digitalis prep-
arations, nonsteroidal anti-inflammatory products,
anticonvulsants, and certain antibiotics (aminogly-
cosides such as gentamycin, tobramycin, and
amikacin which have been known to cause ototoxici-
ty, neurotoxicity, and nephrotoxicity). This may
help to prevent the fatalities and severe morbidity
associated with toxic levels and blood-altering
properties of these drugs.
3. When antibiotic therapy is being considered
to treat a draining wound or cavity, choose the
antibiotic based on the result of a culture and
sensitivity test. Whenever possible, consult with an
infectious disease specialist for treatment of the un-
usual, severe, or nonresponding infection.
4. Make it a habit to consult a good reference
before prescribing a drug for a patient. The vol-
ume of new drugs and the existing older drugs avail-
able for patient treatment is colossal. No one can
retain in his memory all the information necessary
to ensure patient safety and the desired therapeutic
effect. It is of interest that many of the severe medi-
cation errors involved the more common and older
drugs. In addition to the Physicians’ Desk Reference
(PDR) which is provided at no cost to physicians by
the drug companies, consideration should be given
to additional resources (Table). Often PDR lacks
information on older drugs.
5. Consider the hospital or community phar-
macist as a consultant. Updated drug reference
materials such as Drug Facts and Comparisons,
USP-DI, and Facts And Comparisons’ Drug Inter-
actions are kept in pharmacies and pharmacy de-
partments. Education for pharmacists now empha-
sizes their role as a provider of drug information.
Clinical pharmacists with the degree of doctor of
pharmacy (PharmD) are being found in increasing
numbers in New Jersey hospitals. They are gradu-
ates of six or seven years of pharmacy training and
have completed at least one year of residency. The
pharmacist can be considered a source of infor-
mation. ■
Submitted May 1989; Accepted August 1989
34
NEW JERSEY MEDICINE
I
The Contemporary
Alcoholic
NORMAN S. MILLER, MD
MARK S. GOLD, MD
The contemporary alcoholic is younger and addicted to more drugs than ever
before. The alcoholic under the age of 30 years old is addicted to marijuana,
cocaine, benzodiazepines, barbiturates, and other drugs.
The use of drugs other than alcohol by al-
coholics has been sufficiently prevalent for
clinicians and researchers to record in the
past. Alcoholics are using more drugs than ever
before.1'7 The importance of identifying drug use and
addiction in alcoholic populations is crucial to
clinical diagnosis, prognosis, and treatment. The
formulation of research models for the etiology and
natural history of abuse and addiction to alcohol
must consider other drug use and addiction.
The contemporary alcoholic reflects a departure
from the traditional alcoholic in pattern and fre-
quency of other drugs used. Today’s alcoholic is
younger, usually starts with alcohol as the first drug,
and progresses to other drug use rapidly and intense-
ly. Most alcoholics under the age of 30 use at least
one other drug, typically multiple drugs. The use of
the other drugs frequently is addictive and some-
times has indistinguishable consequences from an
alcohol addiction.3,1
Conversely, the majority of the drug addicts who
are addicted initially to a drug other than alcohol
later will develop an alcohol addiction. For these
drug addicts, alcohol usually is not the drug of
choice, but is used as an adjunct for the effects of
a drug or as a substitute for a drug.4'5
Dr. Miller is affiliated with Cornell University Medical Col-
lege. Dr. Gold is associated with Fair Oaks Hospital,
Summit. Requests for reprints may be addressed to Dr.
Miller, The New York Hospital/Cornell Medical Center,
21 Bloomingdale Road, White Plains, NY 10605.
PREVALENCE OF USE
An arbitrary cut-off between young and old al-
coholics is made at 30 years of age to illustrate the
epidemiology of drug use among alcoholics. The in-
VOL. 87— NUMBER 1 JANUARY 1990
35
cidence of drug use by alcoholics decreases as age
increases and reflects the pattern of drug use that
began in the 1960s among the younger popula-
tion.3'6 A complete, and often cited, reference that
illustrates the frequency of alcohol and drug use in
young populations is a monitoring survey conducted
annually since 1975 by the National Institute on
Drug Abuse (NIDA). A nationally representative
sample of high school seniors who are enrolled at the
time of the survey is polled.
The lifetime use by high school seniors in 1986 of
alcohol was 91 percent; marijuana, 51 percent; co-
caine, 17 percent; other stimulants, 23 percent; and
tranquilizers, 11 percent. The use in the most recent
month for the same drugs was 85 percent, 38 percent,
13 percent, 13 percent, and 6 percent, respectively.
Another national survey by NIDA samples house-
holds in the United States for drug use in all ages.
Although similar figures are obtained for the young,
the inverse relationship between age and other drug
use among alcoholics is illustrated in this survey.
Among the adults 26 years of age and older, the
lifetime prevalence in 1985 for alcohol use was 90
percent; marijuana, 27 percent; cocaine, 10 percent;
other stimulants, 8 percent; hallucinogens, 6 per-
cent; and sedatives/tranquilizers, 12 percent.5
The Drug Abuse Warning Network (DAWN), re-
cording visits to emergency rooms in the United
States, has found that alcohol used with other drugs
was cited more frequently than drugs used alone.
This combination of alcohol and drugs accounted for
24 percent of all drug-related episodes in the emer-
gency rooms for all ages, excluding those episodes
related to alcohol alone, for which data were not
collected.6
A national accounting of youths with alcohol and
drug problems in the National Youth Poly-drug
Study (NYPS) revealed that the mean number of
drugs regularly used by the alcoholic youths was 4.4.
Marijuana and alcohol were the most frequently
used drugs on a regular basis, 86 percent and 80
percent, respectively, of the sample of 2,750 youths.
Amphetamines had the third highest prevalence at
45 percent, followed by hashish, barbiturates, hal-
lucinogens, and phencyclindim (PCP) at 42 percent,
40 percent, 40 percent, and 32 percent, respectively.7
From 1930 through 1970, alcoholics’ use of other
drugs has been reported with regular frequency. As
many as 46 percent of 1,340 alcoholic patients (of all
ages in 17 New York alcoholism rehabilitation units)
used drugs, often addictively, during the 30 days
before entering treatment. The drugs most frequent-
ly used were minor tranquilizers, marijuana, seda-
tives, amphetamines, hallucinogens, and narcotics.
Approximately 20 percent of the patients reported
using two or more drugs in addition to alcohol. A
comprehensive review examining 15,447 cases in 46
studies found 3,046 alcoholics who also were ad-
dicted to another drug, a 20 percent rate of drug
addiction among alcoholics. Some of today’s drugs
were reported in the literature from the 1930s
through the 1960s, i.e. barbiturates, opiates,
benzodiazepines, organic solvents, and marijuana.8,9
In recent, large-scale studies of inpatient popu-
lations of adult and adolescent alcoholics and drug
addicts in various treatment facilities, the number
of cocaine addicts with the additional diagnosis of
alcohol dependence was in the 70 to 90 percent
range.10,11 Similar studies of methadone and heroin
addicts show rates of alcohol dependence between 50
and 75 percent.12,13 Approximately 80 to 90 percent
of cannabis addicts also are addicted to alcohol.10,11
The prevalence of poly-drug use and addiction that
includes alcohol is the rule for the contemporary
drug addict. The mono-drug user and addict is a
vanishing species in American culture.12'14
PATTERNS OF USE
Many studies that examine alcoholics separately
from drug addicts indicate that alcohol is the first
drug used, often addictively, by both the alcoholic
whose primary drug of choice is alcohol and the drug f
addict whose primary drug of choice is marijuana or 1
another drug other than alcohol.15 Summarizing i
available studies, alcoholics over the age of 30 typi- I
cally began drinking in adolescence and progressed s
to alcohol dependence in their 20s. A certain propor- t
tion began using cannabis (10 to 20 percent) in their (
adolescence. Another 10 percent began use of stimu- (
lants, including cocaine, amphetamines, and or- j (
ganic solvents, while 20 percent began use of i (
sedative/hypnotics, predominately benzodiazepines, i
barbiturates, and meprobamates. Around 50 percent ]
may continue their alcohol dependence without sig-
nificant use of drugs in addition to alcohol.8,9,14,16,17
The alcoholic under the age of 30 has developed
a different pattern. Over 80 percent of these al-
coholics are addicted to at least one other drug, often
more than one drug. A triad of alcohol, marijuana,
and cocaine addiction is a regular occurrence among
younger alcoholics being admitted currently to inpa-
tient and outpatient facilities.18 Typically, the
younger alcoholic begins using alcohol in early
teenage years, around 13 to 15, progressing to addic-
tive use of alcohol by 15 to 16 years of age. A year
or two after the onset of alcohol use, other drugs are
tried, some addictively, that include marijuana and
cocaine, followed by hallucinogens, benzodia-
zepines, and barbiturates. The pattern of cocaine
use is changing dramatically, most notably by an
earlier age of onset of use and high addiction rates.
The skillful marketing techniques for the cheaper
form of cocaine, “crack,” have lured younger indi-
viduals to repetitive and often addictive use.6,7,10,11,17
36
NEW JERSEY MEDICINE
© Susan J. Freeman
DIAGNOSIS
The dependence syndrome as defined in DSM-III-
R is used to diagnose alcohol and drug dependence
by utilizing the criteria of addiction, tolerance, and
dependence. Investigations into the utility of the
DSM-III-R criteria for diagnosis of the “dependence
syndrome” also have confirmed these trends of mul-
tiple drug use that are occurring among alcoholics.
Clusters of signs and symptoms conform to the
criteria for a common dependence syndrome for al-
cohol and drugs, particularly, alcohol, opiates, and
cocaine.19
The prevalence of multiple drug use by contem-
porary alcohol and drug addicts poses difficulties in
accurate diagnosis. The identification of only alcohol
use in a patient often is tenuous and misleading.
Because denial is a part of the addictive process, an
under-reporting and underestimation of other drug
use is to be expected in a clinical interview, es-
pecially if only the alcoholic is interviewed. Cor-
roborative sources increase the likelihood of obtain-
ing a more accurate estimate of the total pattern and
amount of alcohol and other drug use. These ad-
ditional sources may be family, employer, legal
agencies, and urine and blood testing for drugs.20
Information needed for diagnosis is difficult to
obtain from the alcoholic, sometimes in even the
most obvious cases. The criteria for addiction, in-
cluding preoccupation, compulsive use, and relapse
to alcohol and drugs, are boldly denied by many
alcoholics and drug addicts who are actively using,
and under the influence of, alcohol and drugs. Ques-
tions regarding the development of tolerance and
dependence to alcohol and drugs are equally difficult
to have answered adequately. Persistent pursuit of
the patient by subsequent interviews and a knowl-
edge of the natural history of alcohol and drug use
and addiction often will yield satisfying results when
trying to fully understand the clinical dynamics of
the alcoholic.20
Multiple drug use will determine the clinical pres-
entation of the acute and chronic intoxication syn-
dromes in the alcoholic. A mixture of signs and
symptoms produced by alcohol and drugs may con-
fuse the clinical picture and make the diagnosis of
a specific type of intoxication difficult. Psychiatric
syndromes that are produced by alcohol and, par-
ticularly, by drugs, in the acute and chronic periods
of intoxication, are not easily differentiated from
psychiatric syndromes from other etiologies.
TREATMENT
The complete knowledge of all drug use in the
alcoholic has important implications in the treat-
ment of drug and alcohol withdrawal in the acute
detoxification period, as well as in relapse preven-
tion. Different drugs, including alcohol, may require
individualized detoxification schemes because cross
tolerance and dependence do not exist for all the
drugs. The physiological withdrawal from alcohol is
treated with benzodiazepines, whereas the anergia,
depression, and craving seen in cocaine withdrawal
are treated by bromocriptine.21,22 The persistent de-
lusional and hallucinatory symptoms from PCP are
ameliorated by neuroleptic medication. The
withdrawal syndrome from opiates is treated either
with clonidine or methadone.23,24 Furthermore, the
protracted withdrawal from hallucinogens and other
stimulants in the alcoholic may require prolonged
pharmacological intervention and supportive care.
The nonpharmacological modalities for long-term
VOL. 87— NUMBER 1 JANUARY 1990
37
treatment of alcohol dependence are affected by
other drug use. Individualized education and sup-
port are indicated for specific drugs such as cocaine
and opiates. However, the principles of the
abstinence-based treatment program that includes
Alcoholics Anonymous will work for the alcoholic
who has additional drug addictions. The similarities
among the alcohol and multiple drug addictions are
greater than the differences, so that recovery by
poly-drug alcoholics in self-help groups such as Al-
coholics Anonymous (AA) and Narcotics Anony-
mous (NA) is not only possible, but is more the rule
than the exception. Even individual psychotherapy
should involve the core of both alcohol and drug
addiction and their combined effects on the mind
and behavior.
The risk of relapse to the drug of choice, whether
it be cocaine, opiates, marijuana, or alcohol, is
heightened by the use of any drug, including alcohol.
The need to abstain from all drugs, including al-
cohol, is necessary, with few exceptions.1015'1719
GENETICS
The theoretical implications are interesting to
consider, especially because of the genetic studies of
the recent decades. Twin, adoption, familial, and
high-risk studies have demonstrated a significant
genetic predisposition to alcoholism. Identical twins
are more concordant for alcoholism than fraternal
twins. The biological parent of an adoptee is a more
important determinant of alcoholism than the foster
parent who reared the adoptee. Alcoholism runs in
families. More than 50 percent of alcoholics have a
family history of alcoholism. A child of an alcoholic
is more likely to have certain neurophysiological and
behavioral manifestations in common with other off-
spring of alcoholics than with matched controls
without an alcoholic parent.25
Corresponding studies for the prevalence of al-
cohol dependence in the families of cocaine and
opiate addicts and other drug users have been per-
formed. In one study, the rate of diagnosis of alcohol
dependence in first- or second-degree relatives in the
families of 263 cocaine addicts was greater than 50
percent; more than 132 cocaine addicts had at least
one relative with alcohol dependence by DSM-III-
R criteria.26
Opiate addicts with a parental history of al-
coholism more frequently were diagnosed with con-
current alcoholism. In one study, opiate addicts
(n = 638) had at least one parent with alcohol de-
pendence in 21.3 percent of the families. Opiate ad-
dicts with the diagnosis of alcohol dependence
(n = 216) had a 27.0 percent rate of parental al-
coholism, and opiate addicts (n = 422) without pa-
rental alcohol dependence had a 12.5 percent rate
of alcohol dependence in their families. Among the
opiate addicts with alcohol dependence, those with
parental alcoholism had more severe problems with
alcohol.27
A study of young alcohol users revealed a higher
rate of alcohol-related problems and drug use if a
family history of alcoholism was present in first- and
second-degree relatives. Young alcohol users
without, or with fewer, relatives with alcoholism had
a lower rate of alcohol-related problems and drug
use.28
These findings compare favorably with the famil-
ial studies of alcoholism. Alcoholics have at least a
50 percent probability for a positive family history
of alcoholism. The high rate of alcohol dependence
among cocaine and opiate addicts and drug users
and their families suggests a generalized vulner-
ability that may have a genetic contribution to al-
cohol and drug abuse. The genetic predisposition to
alcoholism may overlap or share transmission with
cocaine, opiates, and other addictions.
THE NEUROBIOLOGY OF ADDICTION
The concurrence of alcohol and drug addiction
provides further theoretical considerations for a neu-
robiological basis for addiction. The loss of control
that underlies all the criteria for addictive behavior
is manifested by a drive to pursue, use, and resort
to alcohol and drugs repetitively and spontaneously.
The substrate for the mechanisms for the drive in
addiction reside in the limbic system.29 The limbic
structures include the amygdalae and septal areas
for mood, the hippocampi for memory association,
and the drive states for hunger, libido, and thirst.
The reward center also is represented among the
limbic structures in the lateral hypothalamus.30
The important features of addiction are subserved
by the functions in the limbic system. Alcohol and
drugs profoundly alter mood and drive states. An
association between alcohol and drugs and the drive
states may be reinforced by the reward center and
recorded in memory by the hippocampi. The drive
states may entrain the use of alcohol and drugs in
a fashion similar to their autonomous control over
their other functions. The pursuit and use of drugs
and alcohol become as easily stimulated and spon-
taneous as eating, drinking, and sexual behavior.31
Cocaine may activate the limbic system through
stimulation of the dopamine transmission.32 The re-
ward system consists of neurons located in the
lateral hypothalamus that traverse the median fore-
brain bundle to synapse on dopamine-containing
neurons in the ventral tegmentum. These dopamine
neurons send fibers into the nucleus accumbens
(mesolimbic pathway) and the limbic cortex
(mesocortical pathway). Neurons with opiate recep-
tors for endorphins and enkephalins are located on
the dopamine neurons in the ventral tegmentum.
38
NEW JERSEY MEDICINE
Alcohol appears to have a widespread effect on many
of the neurotransmitter systems in the limbic system
and reward system. All of the drugs of addiction,
including alcohol, affect mood, libido, memory, and
appetite. These drugs also may stimulate the
mesolimbic area that may be responsible for halluci-
nations and delusions. All the drugs suppress frontal
lobe function to produce impairment in judgment
and insight characteristic of these addictions.3031
SUMMARY
Multiple drug use occurs in alcoholics in an age-
dependent relationship. The younger the onset of
alcoholism, the more likely is additional drug use.
Drugs used by alcoholics, in decreasing order of fre-
quency, are marijuana, cocaine, and other stimu-
lants, phencyclidine, benzodiazepines, barbiturates,
and hallucinogens. Evaluation of intoxication and
treatment or detoxification in alcoholics should
always include consideration of other drugs. Mul-
tiple drug use in alcoholics does not preclude the
short- or long-term treatment that traditionally is
available for alcoholics, such as programmatic treat-
ment and AA and NA and psychotherapy. The ex-
istence of poly-drug addiction in alcoholics and of
alcohol dependence in families of drug addicts and
alcoholics suggest a common genetic vulnerability to
alcoholism and drug addiction. ■
Submitted: April 1989; Accepted: June 1989
REFERENCES
1. Sokolow L, Welte J, Hynes G, Lyons J: Multiple
substance abuse by alcoholics. Br J Addict 76:147-158,
1981.
2. Mirin SM, Weiss RD, Michael J: Alcohol abuse in
patients dependent on other drugs. Psychiatr Ann
12:430-433, 1982.
3. Refroe CL, Messinger TA: Street drug analysis. An
11-year perspective on illicit drug alteration. Sem Adoles-
cent Med 1:247-257, 1985.
4. Jekel JF, Allen DF: Trends in drug abuse in the
mid-1980s. Yale J Biol Med 60:45-52, 1987.
5. Clayton RR: The epidemiology of alcohol and drug
abuse among adolescents. Adv Alcohol Subst Abuse
4:69-87, 1985.
6. Meltzer HF, Kreek MJ: Multiple drug abuse pat-
terns and medical consequence, in Psychopharmacology:
The Third Generation of Prognosis. New York, NY, Raven
Press, pp. 1597-1604, 1987.
7. Santo Y, Farley EC, Friedman AS: Highlights from
the National Youth Poly-drug Study, in, Drug Abuse Pat-
terns among Young Poly-drug Abusers and Urban Ap-
palachian Youths. U.S. Dept, of Health and Human Ser-
vices, Publication No. 80-1002, 1-16, 1980.
8. Freed EX: Drug abuse by alcoholics: A review. Int
J Addict 8:451-473, 1973.
9. Sokolow L, Welte J, Hynes G, Lyons J: Multiple
substance abuse by alcoholics. Br J Addict 76:147-158,
1981.
10. Miller NS, Gold MS: The diagnosis of alcohol de-
pendence and cannabis dependence among cocaine ad-
dicts (submitted for publication), 1988.
11. Miller NS, Millman RB, Keskinen S: The preva-
lence of alcohol dependence among cocaine addicts in an
inpatient population (submitted for publication), 1988.
12. Liebson F, Bigelow G, Flainer R: Alcoholism among
methadone patients. A specific treatment method. Am J
Psychiatry 130:483-485, 1973.
13. Birrhari B: Alcoholism and methadone mainte-
nance. Am J Drug Alcohol Abuse 1:79-87, 1974.
14. Carrol JFX, Santo Y, Hannigan PC: Description of
the total client sample, analysis of substance use patterns
and individual program descriptions, chapter III, in,
Gardner SE, National Drug/Alcohol Collaborative Project
Issues in Multiple Substance Abuse. Research Monograph
Services, NIDA DHEW Publication No. (ADM) 80-957,
1980.
15. Gold MS: Drugs of Abuse: A Comprehensive Series
for Clinicians. Vol. 1. Marijuana. New York, NY, Plenum
Medical Book Company, 1989.
16. Kanaia J, Kofoed L: Drug use by alcoholics in out-
patient treatment. Am J Drug Alcohol Abuse 10:529-534,
1984.
17. Smith DE: Cocaine-alcohol abuse: Epidemiological,
diagnostic, and treatment considerations. J Psychoactive
Drugs 18:117-129, 1986.
18. Gold MS: The Facts About Drugs and Alcohol. New
York, NY, Bantam Books, 1987.
19. Kosten TR, Rounsaville BJ, Babor TF, et al.:
Substance-use disorders in DSM-III-R evidence for the
dependence syndrome across different psychoactive
substance. Br J Psychiatry 151:834-843, 1987.
20. Miller NS: A primer of the treatment process for
alcoholism and drug addiction. Psychiatry Letter 5:30-37,
1987.
21. Extein IL, Gold MS: The treatment of cocaine ad-
dicts: Bromocriptine or desipramine. Psychiatr Ann
18:535-537, 1988.
22. Dackis CA, Gold MS: Bromocriptine as treatment
of cocaine abuse. Lancet 1:1151-1152, 1985.
23. Miller NS, Gold MS, Millman RB: PCP: A danger-
ous drug. Am Fam Pract 38:215-218, 1988.
24. Tennant F: Clinical diagnosis and treatment of
postdrug impairment syndrome. Psychiatry Letter
6:47-51, 1988.
25. Goodwin DW: Alcoholism and genetics: The sins of
the fathers. Arch Gen Psychiatry 42:171-174, 1985.
26. Miller NS, Gold MS, Belkin BM, Klahr AL: Family
history and diagnosis of alcohol dependence in cocaine
dependents (in press), 1988.
27. Kosten TR, Rounsaville BJ, Kleber HD: Parental
alcoholism in opioid addicts. J Nerv Mental Dis
173:461-468, 1985.
28. Schuckit MA, Sweeney S: Substance use and men-
tal health problems among sons of alcoholics and controls.
J Studies Alcohol 48:528-534, 1987.
29. Gold MS, Dackis CA: New insights and treatments:
Narcotics and cocaine addiction. Clin Ther 7:6-21, 1985.
30. Lader M: The psychopharmacology of addiction.
New York, NY, Oxford University Press, 1988.
31. Miller NS, Dackis CA, Gold MS: The relationship
of addiction, tolerance, and dependence: A neurochemical
approach. J Substance Abuse Treatment 4:197-207, 1987.
32. Dackis CA, Gold MS: New concepts in cocaine ad-
diction: The dopamine depletion hypothesis. Neu-
roscience Biobehavioral Rev 9:469-477, 1985.
VOL. 87— NUMBER 1 JANUARY 1990
39
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NEW JERSEY MEDICINE
Whipple Operation
Revisited
DAVID A. SPAIN, MD
RALPH S. GRECO, MD
The Whipple procedure traditionally is associated with an operative mortality
of 20 to 25 percent. /As a result, percutaneous and endoscopic techniques
have been advocated to alleviate symptoms in patients with periampullary
carcinoma. Now, dramatic reductions in operative mortality rates have been
reported. Since radical pancreaticoduodenectomy is the only treatment for
cure, a re-evaluation of the role of this procedure is warranted.
Modern pancreatic surgery began in 1935
when Whipple introduced a two-stage
radical pancreaticoduodenectomy for the
treatment of carcinoma of the ampulla of Vater.1
This was modified to a single-stage procedure by
Trimble in 1941. 2 At that time, the fear of a pan-
creatic-intestinal anastomosis was so great that the
pancreatic duct was simply ligated. This led to pan-
creatic fistula formation in up to 70 percent of pa-
tients.3 During the next 30 to 40 years, despite ad-
vances in surgical techniques, septic complications
from leakage of the pancreatic-jejunal anastomosis
were frequent. The high operative morbidity and
mortality rates and poor long-term survival in
periampullary cancers caused surgeons in the 1960s
and 1970s to call for abandonment of this procedure.
In 1970, Crile reported that survival in patients with
Dr. Spain is a resident in general surgery and Dr. Greco
is professor and chief, Division of General Surgery,
UMDNJ-Robert Wood Johnson Medical School, New
Brunswick. Requests for reprints may be addressed to
Dr. Greco, UMDNJ-Robert Wood Johnson Medical
School, 1 Robert Wood Johnson Place, CN 19, New
Brunswick, NJ 08903-0019.
biliary bypass was greater than those with resection.4
However, this study was limited to patients with
adenocarcinoma of the head of the pancreas and a
palpable mass, and, therefore, does not apply to all
patients with periampullary tumors.
Radical pancreaticoduodenectomy offers the only
chance for cure in patients with periampullary
cancers, which now are the fourth leading cause of
death from cancer.5 Despite advances in diagnostic
capabilities, it often is difficult to distinguish the
origin of the four tumors found in the periampullary
region: pancreatic, ampullary, common bile duct,
and duodenal. Five-year survival rates vary
drastically depending on the site of origin, from as
low as 3 percent for pancreatic cancer to as high as
60 percent for ampullary cancer,6'8 but laparotomy
may be the only way to identify a more favorable
lesion. In order to justify the more frequent use of
this procedure, morbidity and mortality rates must
be decreased. Recent reports from Johns Hopkins
University, UCLA Medical Center, and other in-
stitutions have reported operative mortality rates as
low as 1 to 6 percent, well below the oft-quoted 25
percent.79 These reports and experience with a re-
VOL. 87— NUMBER 1 JANUARY 1990
41
cent patient prompted us to review radical pan-
creaticoduodenectomy at Robert Wood Johnson
University Hospital. Unfortunately, the traditional
view that the Whipple procedure carries a
prohibitive mortality has remained with many in-
ternists, gastroenterologists, radiologists, and sur-
geons. A nonoperative approach using percutaneous
or endoscopic techniques to alleviate symptoms has
Table 1. Presenting signs and symptoms.
Number Percent
Jaundice
11
92
Bilirubinuria
7
58
Diarrhea/Acholic Stool
7
58
Weight Loss
6
50
Abdominal Pain
4
33
Pruritis
4
33
Abnormal liver function tests
1
8.3
been advocated for an ever-increasing number of
patients. A case report illustrates the limitations of
the nonoperative approach and the advantages of an
aggressive surgical attitude towards patients with
periampullary tumors.
CASE REPORT
A 59-year-old white female, with a history of
asthma and atrial arrhythmias, was seen initially at
another hospital for vague right upper quadrant ab-
dominal pain associated with anorexia and weak-
ness. A diagnosis of biliary colic was made, and when
her symptoms subsided, she was discharged from the
emergency room. She felt well for two weeks and
then noticed the gradual onset of jaundice and a 15-
pound weight loss. She was admitted to the hospital
for evaluation. A computed tomography (CT) scan
of the abdomen was performed and reported to show
an extensive mass in the head of the pancreas, which
was felt to be unresectable. An endoscopic retro-
grade cholangiopancreatography (ERCP) was at-
tempted, but the ampulla could not be identified.
A large mass impinging on the second portion of the
duodenum was found. A biopsy was positive for
adenocarcinoma. She was transferred to the Robert
Wood Johnson University Hospital Surgical Service
for evaluation.
Physical examination revealed an icteric woman
with normal vital signs. Her lungs were clear and the
cardiac rhythm regular. The abdomen was soft with
slight right upper quadrant tenderness. A 6 cm gall-
bladder was palpable in the right upper quadrant.
The liver span was 8 cm. The rectal examination was
normal and the stool negative for blood.
Laboratory data were significant for a total
bilirubin of 8.0 mg percent with a direct of 6.0 mg
percent, and elevation of all liver enzymes including
an alkaline phosphatase of 640 U/L (normal 0 to 75
U/L). A visceral arteriogram revealed a right hepatic
artery originating from the superior mesenteric ar-
tery and displacement of the superior mesenteric
vessels by the tumor mass. Encasement of a minor
inferior pancreaticoduodenal artery branch was seen
as well.
Table 2. Operative data.
1980-1988
(n = 12)
1980-1984
(n — 6)
1985-1988
(n = 6)
Operative Time
8 hr 14 m
9 hr 20 m
7 hr 8 m
Estimated Blood
2010 cc
2400 cc
1620 cc
Loss
Intraoperative
3.9 units
4.6 units
3.3 units
Transfusions
Morbidity
58.3%
66.7%
50.0%
Mortality
0%
0%
0%
At this point, the impression was that the patient
had a pancreatic head cancer that appeared unre-
sectable. Physicians involved in her care offered sev-
eral treatment modalities to the patient, including
percutaneous biliary drainage. We strongly felt this
patient should have an exploratory laparotomy and
possible radical pancreaticoduodenectomy, as this
offered the only chance for cure. The patient agreed
and underwent a Whipple procedure with an opera-
tive time of four hours and 14 minutes. Estimated
blood loss was 500 cc and no transfusions were re-
quired. Pathologic examination of the specimen re-
vealed a well-differentiated adenocarcinoma of the
ampulla of Vater (Figure). The margins were free of
tumor and all nodes were negative. The patient’s
postoperative course was uneventful and she was
discharged on postoperative day 10.
RESULTS
Twelve patients have undergone elective radical
pancreaticoduodenectomy at Robert Wood Johnson
University Hospital from 1980 to 1988. All were per-
formed for carcinoma. There were 9 males and 3
females with an average age of 62 years (range 54
to 73 years). The oldest patient now is 76 years old
and alive and well without evidence of disease. Pre-
senting signs and symptoms are listed in Table 1.
The average duration prior to presentation was 5
weeks (range 1 to 12 w'eeks). Seven patients had
pancreatic tumors and 3 patients had negative
nodes. There were 2 patients with ampullary and 1
patient with common bile duct cancer, all with
negative nodes. Both patients with primary
duodenal cancer had positive nodes.
Operative data for all patients are presented in
Table 2. The cases are divided into two time periods
42
NEW JERSEY MEDICINE
Figure. Gross pathology specimen revealing a 5 x 5 cm mass of the ampulla of Vater. The probe is through the common
bile duct.
VOL. 87— NUMBER 1 JANUARY 1990
43
for comparison. There were no perioperative deaths
in either group and all patients were discharged
home. During the last four years, operative time,
estimated blood loss, and the number of intra-
operative transfusions all have decreased. Morbidity
remained high at 50 percent but decreased from 66.7
percent for the previous time period. Five patients
had no complications and were discharged between
10 and 24 days. Three patients (33 percent) had the
major complication of an anastomotic leak with
intra-abdominal abscess: two patients were drained
percutaneously and one patient required a second
laparotomy. Three patients developed postoperative
diabetes mellitus, but easily were controlled with
modest doses of insulin.
DISCUSSION
The Whipple procedure remains one of the most
complex and difficult intra-abdominal operations
performed. Historically, the operative mortality
rates have been 20 to 25 percent.10 Because of this
and the poor long-term prognosis for pancreatic
cancer, there has been a great hesitancy to subject
patients to this procedure. Recent developments in
endoscopy and interventional radiology have
provided nonoperative methods to alleviate symp-
toms in patients with periampullary cancers. This
philosophy, however, ignores the well-documented
decrease in operative mortality rates to 3 to 10 per-
cent.7911 Grace and Longmire from UCLA had an
operative mortality rate of 6 percent in 96 patients,
and this had further decreased to 2 percent in the
last five years of their study.7 In 1984, Trede reported
an operative mortality of 1.1 percent in 91 con-
secutive patients and found that the resectability
rate also had increased from 5 to 21 percent during
the study.11 Advances in perioperative care, includ-
ing intensive care unit monitoring and total parent-
eral nutrition, and improved treatment of peri-
operative complications through interventional
radiology may account for these changes. Cameron
believes the most important reason for the decline
is that more patients are being sent to experienced
pancreatic surgeons at regional centers.12
Overall survival in pancreatic cancer appears to
be increasing, although the reasons for this are un-
clear.9 Cameron reported an actual five-year survival
of 19 percent in all patients with pancreatic cancer
undergoing a Whipple procedure; however, lymph
node involvement was critical.12 Five-year actuarial
survival was 1 percent in node positive patients, and
48 percent in those with negative nodes. Three of our
patients fall into the latter category. In 1986, the
UCLA Medical Center reported a five-year actuarial
survival after resection of 52 percent in common bile
duct cancer, 60 percent in duodenal cancer and 62
percent in ampullary cancer.7 Therefore, 6 of 12 pa-
tients in our study would be expected to have a 40
to 60 percent chance of surviving five years. In par-
ticular, the patient presented would have been poor-
ly served with a nonoperative approach or simple
biliary bypass.
Clearly, the prevailing attitude toward radical
pancreaticoduodenectomy must be re-evaluated.
Furthermore, nonoperative approaches must be re-
evaluated as well, with specific regard to the quality
of survival. There is one point upon which all
specialists dealing with this problem agree: patients
who are denied operations will die of their disease.
Patients now may be offered a potentially curable
operation with an acceptable mortality. Although
complications still are common and the overall prog-
nosis is variable, we must not become pessimistic.
Radical pancreaticoduodenectomy offers the only
chance to cure these patients. An aggressive surgical
approach should be undertaken in all patients with
periampullary lesions unless there is unequivocal
evidence of metastatic disease. ■
Submitted: May 1989; Accepted: July 1989
REFERENCES
1. Whipple AO, Parsons WB, Mullins CR: Treatment
of carcinoma of the ampulla of Vater. Ann Surg
102:763-779, 1935.
2. Trimble IR, Parsons JW, Sherman CP: A one-stage
operation for the cure of carcinoma of the ampulla of Vater
and head of the pancreas. Surg Gynecol Obstet 73:711-727,
1941.
3. Papachristou DN, D’Agistino H, Fortner JG: Liga-
tion of the pancreatic duct in pancreatectomy. Br J Surg
67:260-262, 1980.
4. Crile G Jr: The advantage of bypass operation over
radical pancreaticoduodenectomy in the treatment of pan-
creatic carcinoma. Surg Gynecol Obstet 130:1049-1053,
1970.
5. Silverberg E: American Cancer Society. Cancer
Statistics 36:9-16, 1986.
6. Connolly MM, Dawson PJ, Michelassi F, et ah:
Survival in 1001 patients with carcinoma of the pancreas.
Ann Surg 206:366-373, 1987.
7. Grace PA, Pitt HA, Tompkins RK, et ah: Decreased
morbidity and mortality after pancreaticoduodenectomy.
Am J Surg 151:141-149, 1986.
8. Hayes DH, Bolton JS, Willis GW, Bowen JC:
Carcinoma of the ampulla of Vater. Ann Surg 206:572-577,
1987.
9. Crist DW, Sitzman JV, Cameron JL: Improved hos-
pital morbidity and mortality after the Whipple
procedure. Ann Surg 206:358-365, 1987.
10. Shapiro TM: Adenocarcinoma of the pancreas: A
statistical analysis of biliary bypass versus Whipple resec-
tion in good risk patients. Ann Surg 182:715-721, 1976.
11. Trede M: The surgical treatment of pancreatic
carcinoma. Surgery 97:28-35, 1985.
12. Cameron JL: Current status of the Whipple oper-
ation for periampullary carcinoma. Surgical Rounds 77-87,
1988.
44
NEW JERSEY MEDICINE
MEDICAL HISTORY
Thomas Jefferson
University
Tradition and Heritage
MORRIS H. SAFFRON, MD
This ponderous and unwieldly volume (edited
by Frederick B. Wagner, Jr, MD, Lea and
Febiger, Philadelphia and London, 1989)
contains the most detailed account of any medical
school in the United States. Written and in large
part edited by a Jefferson professor of surgery who
also is University historian, the work is a composite
by many hands, including specialists in various
fields as well as collateral administrators. This essay
will concern itself primarily with the 19th century
history of the school as it relates to the development
of medical education in this country.
Jefferson College, the first literary institution
founded west of the Alleghenies, was chartered in
1802 during the administration of our third president
who showed his pleasure at the name by donating
books and money to the school. As a result, a
tenuous relationship with the University of Virginia
seems to have persisted for a considerable period of
time. However, it was not until 1824 that a medical
school located in Philadelphia was engrafted on the
parent college. Two years later, despite strenuous
efforts on the part of the University of Pennsylvania
to prevent such a move, the state Legislature
authorized the new school to grant the medical
degree. The animus between the two schools per-
sisted for many years and as late as the 1830s, it was
stated that “the faculty of the University of Penn-
sylvania could take no notice of anything that
emanated from the Jefferson School.” The prime
Dr. Saffron is archivist/historian of the Medical Society
of New Jersey, and a member of the Editorial Board of
NEW JERSEY MEDICINE. Requests for reprints may be
addressed to Dr. Saffron, Medical Society of New Jersey,
Two Princess Road, Lawrenceville, NJ 08648.
mover in the stirring events connected with the foun-
dation of Jefferson was the surgeon George
McClellan, himself a Pennsylvania graduate. He
was assisted by three other faculty members, one of
whom was the noted John Eberle, an early pedia-
trician whose Treatise on the Practice of Medicine
ran through no less than six editions.
The 1830s, the so-called Jacksonian era, witnessed
a general lowering of educational standards with the
concomitant rise of a number of poorly organized
proprietary medical schools, many of which ex-
perienced a rapid demise. Jefferson itself suffered
from many vicissitudes, including a difficulty in re-
taining faculty members as well as financial prob-
lems before reaching a period of relative calm.
Among the prominent teachers of these early days
were: botanist William P. C. Barton, professor of
materia medica, whose Flora of North America is
highly regarded and Nathan R. Smith, a surgeon
who already had founded two medical schools in
Vermont and at Dartmouth before coming to Jef-
ferson. Another transient faculty member was the
remarkable medical pioneer, Daniel Drake, who
taught at several schools and was the founder of two
others in Ohio. He is noted as author of the classic
Diseases of the Interior Valley of North Am erica, the
first textbook on the subject. Still another peri-
patetic who touched base at Jefferson was the
Scotsman Grenville S. Pattison, a famous anatomist
who soon wandered off to help found the medical
school at New York University.
At this period, the class of 1835 produced two
graduates whose names still are revered in the his-
tory of medicine: Carlos J. Finlay, the Cuban phy-
sician who apparently was the first to attribute the
VOL. 87— NUMBER 1 JANUARY 1990
45
MEDICAL HISTORY
cause of malaria to the bite of a mosquito, and J.
Marion Sims, whose skill in the repair of vesico-
vaginal fistulae brought him the title, father of
American gynecology, and a statue in New York’s
Central Park. Somewhat later, another famous
graduate was Edward R. Squibb, who devised a
method of freeing ether from its impurities and went
on to establish the famous pharmaceutical house
which still bears his name.
The year 1838 saw the final separation of Jefferson
Medical School from the parent college. The ensuing
year was one of turmoil and dissension ending with
the dismissal of the founding father, George
McClellan, and the selection of a basically new fac-
ulty. Prominent among the appointees were Robley
Dunglison, professor of medicine, and Charles D.
Meigs, professor of obstetrics and gynecology. Both
of these men were prolific writers and their numer-
ous publications helped bring increased recognition
to the “second” Philadelphia school. Indeed, it was
the highly cultured Meigs who obtained a somewhat
dubious notoriety for himself by his vigorous opposi-
tion to the Holmes-Semmelweiss theory of post-
partum contagion induced by the uncleanliness of
the obstetrician. A rigorous traditionalist, Meigs
later opposed the use of anesthesia during child-
birth. In 1847, at the founders meeting of the Ameri-
can Medical Association, it was a Jefferson professor
of medicine, Nathaniel Chapman, who was named
first president by acclamation.
We now are approaching the antebellum period
and the arrival from Louisville of Samuel D. Gross
as professor of surgery. Gross succeeded Thomas D.
Mutter whose name is perpetuated in the famous
anatomical museum now housed in the College of
Physicians of Philadelphia. During his long and pro-
ductive tenure (1856-1882), Gross became recog-
nized as dean of surgery in America, and the numer-
ous accolades he received on his many trips here and
abroad naturally brought permanent lustre to the
institution which he represented. The famous paint-
ing by Thomas Eakins, “The Gross Clinic,” is rec-
ognized as a masterpiece of American painting. In-
cidentally, the connection between the artist, who
insisted on emphasizing the value of anatomical
studies to his pupils, and the nearby medical school
was very close, with the result that the numerous
portraits of faculty members done by Eakins remain
among Jefferson’s most prized possessions.
The Civil War brought a period of hardship to
Jefferson as many southern students withdrew to
join the Confederate forces. Gross immediately
produced a “Manual of Military Surgery” which
promptly was pirated by the southerners and soon
became a veritable vade mecum for medical officers
on both sides of the struggle. By the end of the war,
Jefferson had become firmly established as a leading
school of medicine in this country. Among the
notables on the faculty we can mention only a few:
John W. Brinton, a founder of the Army Medical
Museum and collaborator with William H. Ham-
mond in the publication of the voluminous, Medical
and Surgical History of the War of the Rebellion;
William W. Keen, a prolific writer on anatomy and
surgery noted for performing the first successful op
eration for brain tumor; and John P. da Costa whose
work on surgery went through ten editions. In other
fields, we may mention the unrelated though equally
famous clinician, Jacob M. da Costa, whose Medical
Diagnosis long held supremacy in the field; Jacob
da Silva Solis-Cohen, a pioneer in the specialty of
laryngology; Hobart A. Hare, whose work on thera-
peutics was reprinted no less than 21 times; and S.
Weir Mitchell, often called the father of neurology
in this country, who is equally revered for his
eminence in the field of the American novel.
Jefferson sailed through the Flexner probe of 1910
to 1911 with flying colors, and as we approach recent
times, the names of faculty leaders in medicine be-
come ever more frequent: Elmer H. Funk who ex-
panded Trudeau’s sanatorium treatment for tu-
berculosis; Martin E. Rehfuss, the gastroenterologist
whose name is linked with his tube for gastric
analysis; Charles E. Sajous and Francis X. Dercum,
pioneers in the development of the science of en-
docrinology; Jay F. Schamberg, the dermatologist
who collaborated in the manufacture of
arsphenamine when this substance could not be ob-
tained from Germany during World War I; George
E. de Schweinitz, famous ophthalmologist whose
Diseases of the Eye, first published in 1892, ran
through ten editions; and Chevalier Jackson, an in-
novator in the field of bronchoscopy who improved
instruments used in removing foreign objects from
the food and air passages.
As previously indicated, the latter half of this vol-
ume is concerned with the development of the vari-
ous specialties. Written in each instance by the cur-
rent head of the department, these introductory ac-
counts should prove of considerable interest to fu-
ture scholars. Unfortunately, in the case of the older
disciplines such as surgery and medicine, there is a
noticeable degree of overlapping and repetition
which occasionally mar this otherwise splendid
work. At times, identical photographs are repro-
duced. A number of portraits seems to be legion and
in the case of Samuel D. Gross, I counted no less
than four, with two duplicates of the sword carried
by his son during the Civil War. In spite of such
laudable, if frequently overwhelming, efforts to at-
tain absolute completeness, this book certainly will
prove to be a landmark in the field, and one which
future institutional historians will wish to explore
and emulate. ■
46
NEW JERSEY MEDICINE
CASE REPORT
Malignant Fibrous
Histiocytoma
Induced by Thorium
MARK T. DIMARCANGELO, DO
ERIBERTO T. DAVID, MD
KOSON KURODA, MD
Thorium dioxide is a deleterious substance that was employed as a vascular
contrast medium during the early 20th century. Our report entails a unique
neoplastic complication of thorium administration.
We report the interesting and unusual his-
tory of a patient exposed to the contrast
medium, thorium dioxide, during the sec-
ond decade of her life. The patient then developed
an extraosseous malignant fibrous histiocytoma of
her lower extremity during the sixth decade of life.
The authors are affiliated with the Department of
Diagnostic Radiology and Nuclear Medicine, Cooper
Hospital/University Medical Center, Camden. Requests
for reprints may be addressed to Dr. DiMarcangelo,
Cooper Hospital/University Medical Center, 1 Cooper
Plaza, Camden, NJ 08103.
To our knowledge, this is the first report of this rare,
latent complication of thorium exposure.
CASE REPORT
A 57-year-old woman was admitted to Cooper
Hospital/University Medical Center, Camden, in
November 1987, with a mass involving the right
thigh, accompanied by edema of the entire lower
extremity. At age 11, the patient sustained a severe
laceration to the right thigh, that was repaired
surgically. At age 14, she developed painful right
lower leg varicosities. She underwent a venogram
VOL. 87— NUMBER 1 JANUARY 1990
47
CASE REPORT
with thorotrast (thorium dioxide), at which time
there was soft tissue extravasation of the thorotrast
into the right thigh and pelvis. The patient could not
recall the site of the contrast injection. She subse-
quently had two venous ligation procedures to treat
the varicosities.
Six years prior to the present admission, the pa-
tient had a frontal meningioma excised. Approx-
imately 24 months before this admission, a mass
developed in the right thigh, that was diagnosed
as a malignant fibrous histiocytoma (MFH). The
neoplasm was resected and followed by radiation
therapy (6500 rads) to the surgical bed.
Within 24 months, the thigh mass recurred and
outpatient chemotherapy with Adriamycin® and
Methotrexate® was initiated. The tumor, however,
was refractory to this therapy, necessitating hospi-
talization.
On this admission, the plain film examination of
the abdomen and abdominal computed tomography
(CT) imaging demonstrated sequestration of
thorotrast within the spleen and the lymph nodes
(Figures 1 and 2). As might be expected, the spleen
was noted to be diminished in size secondary to
Figure 1. The plain abdominal radiograph shows thorotrast
within the spleen (arrow) and multiple lymph nodes (ar-
rowheads).
radiation-induced atrophy. Radiographic examin-
ation of the right hemipelvis and thigh demon-
strated thorotrast within the musculature and adja-
cent soft tissues as well as within regional lymph
nodes (Figure 3). Arteriography, preliminary to sur-
gery, revealed tumor blush within the right thigh
mass (Figure 4).
A total right lower extremity amputation (right
hip disarticulation) was done. Surgical recovery was
uneventful and there was no evidence of other
neoplastic process at the time of discharge. A third
primary neoplasm has been discovered in the upper
lobe of the right lung; histology has yet to be estab-
lished, but it is thought to be a carcinoma.
PATHOLOGICAL FINDINGS
Gross pathological analysis of the amputated
thigh revealed an oval, circumscribed, rubbery,
white and pale gray tumor measuring 14 x 11 x 6
cm. The mass involved the skeletal musculature and
extended into the subcutaneous fat. Osseous in-
volvement was not found, but there was impinge-
ment upon the femoral vessels and evidence of cen-
tral tumor necrosis. The microscopic examination
again demonstrated findings consistent with malig-
nant fibrous histiocytoma of the storiform
pleomorphic variety. Thorotrast granules were pres-
ent in the microscopic sections.
DISCUSSION
Thorium dioxide (thorotrast) is a radioactive
substance that predominantly emits alpha particles.
This agent was utilized as a contrast medium after
its introduction in 1928.' Thorium-232, present in
thorotrast, has a biological half life of 400 years and,
when introduced into the body, it is sequestered by
the reticuloendothelial system. The alpha particles
are responsible for high radiation dosage to these
Figure 2. Computed tomogram of the upper abdomen confirms i
the presence of thorotrast ih the spleen (arrow) and lymph
nodes (small arrowheads). Radiopaque contrast is present
within the stomach (large arrowhead).
48
NEW JERSEY MEDICINE
CASE REPORT
Figure 3. Plain film of the right hemipelvis and upper thigh
depicts thorium within the soft tissues and lymph nodes.
tissues and can culminate in carcinogenesis. After
the first report in 1947 of neoplasia related to
thorotrast administration,2 the angiographic use of
this deleterious material was abandoned. Many
papers since have described the malignancies as-
sociated with thorotrast. The types of tumors cited
in the literature include various hepatic and splenic
lesions,1 meningioma,3 4 leukemia/ lung carcinoma,5
renal cell carcinoma,6 mesotheliomas, and sarcomas
of the bone and soft tissues of the neck.7 No reports
were found of thorium-induced MFH of the lower
extremity. It is interesting to note that, although
MFH usually is osseous in origin, this patient’s
Figure 4. Arteriogram reveals smooth narrowing of the proxi-
mal portion of the superficial femoral artery secondary to adja-
cent mass effect (arrow). Tumor blush and neovascularity also
are present (arrowheads).
neoplasm was totally extraosseous in location.
A thigh malignancy occurring in an area where
there had been thorotrast deposition 21 years earlier
is consistent with thorotrast-induced neoplasia. As
systemic thorotrastosis was noted on radiography
and CT of the abdomen, it is probable that the three
primary neoplasms in this patient (meningioma,
MFH, and lung carcinoma) can be attributed to the
administration of thorium dioxide. ■
Submitted: April 1989;
Accepted: September 1989
REFERENCES
1. Levy D, Rindsberg S, Friedman A, et al.: Thorotrast-
induced hepatosplenic neoplasia: CT identification. Am J
Roent 146:997-1004, 1986.
2. Kaplan A, Teng S, Koo A: CT Recognition of
thorotrast-induced intracranial and lumbar arachnoiditis.
Am J Neuro Rad 5:323-325, 1984.
3. Kyle R, Oler A, Lasser E, Rosomoff H: Meningioma
induced by thorium dioxide. N Engl J Med 268:80-82,
1963.
4. Boggs D, Kaplan S: Cytobiologic and clinical aspects
in a patient with chronic neutrophilic leukemia after
thorotrast exposure. Am J Med 81:905-910, 1986.
5. Sadahira Y, Mori M, Nakamoto S, et al.: Lung
cancer in a thorotrast-administered patient. Acta Pathol
Jpn, 35:1467-1473, 1985.
6. Kauzlaric D, Barmeir E, Lusieti P, et al.: Renal
carcinoma after retrograde pyelography with thorotrast.
Am J Roent 148:897-898, 1987.
7. Silpananta P, Illescas F, Sheldon H: Multiple malig-
nant neoplasms 40 years after angiography with
thorotrast. Can Med Assoc J 128:289-292, 1983.
VOL. 87— NUMBER 1 JANUARY 1990
49
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NEW JERSEY MEDICINE
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Sharing With
Date of Arrival Time
Date of Departure Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the CLARIDGE or complete the following:
Card # Type Exp. Date
SCHEDULE OF RATES SUBJECT TO 12% TAX
□ SINGLE $75.00 □ One-Bedroom Suite $225.00 □ Two-Bedroom Suite $300.00
□ DOUBLE $75.00 (Reservations must be received prior to April 5, 1990)
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
VOL. 87— NUMBER 1 JANUARY 1990
51
NOTEBOOK
■ TRUSTEES’ REPORT ■
A regular meeting of the Board
of Trustees was held on November
19, 1989, at the executive offices of
the Medical Society of New Jersey.
Detailed minutes are on file with
the secretary of your county so-
ciety. A summary of significant ac-
tions follows:
Frank R. Begen, MD . . . Noted
that a contribution was made to
the MSNJ Medical Student Loan
Fund in memory of Doctor Begen,
and received unanimously the fol-
lowing memorial resolution:
Whereas, the Almighty has chosen to
call from us our beloved colleague,
Frank R. Begen, MD; and
Whereas, as a fellow and officer of this
Society, Doctor Begen served its mem-
bers and the people of New Jersey; and
Whereas, he demonstrated the at-
tributes of a concerned caring father,
husband, and physician, and will be
missed by all; now therefore be it
Resolved, that the Medical Society of
New Jersey expresses its profound sor-
row at the death of Dr. Begen and ex-
tends its sympathy to his family; and
be it further
Resolved, that this Resolution be
spread upon the minutes of this meet-
ing, and a copy t hereof presented to his
family in heartfelt sympathy.
Report of the President . . .
(1) Conference of Presidents . . .
Reported that the Conference was
well attended, and will continue to
be used as a forum for updating the
leadership of the physician com-
munity on current issues of the So-
ciety.
(2) Medical Books for China In-
ternational Foundation . . . Will
encourage membership to partici-
pate in this project to collect used
medical books for China.
(3) JEMPAC . . . Noted that Drs.
Anthony P. Caggiano and Hormoz
M. Minoui will serve with Dr.
Hirsch on the Nominating Com-
mittee as Dr. Ryan will not seek
reappointment as chairman; and,
noted that a number of trustees
have joined JEMPAC.
(4) President’s Page . . . Noted
that Dr. Hirsch, in his column in
the December 1989 issue of NEW
JERSEY MEDICINE, responded
to a letter that expressed a con-
trary viewpoint about political ac-
tion.
(5) Unified Membership in AMA
. . . Heard Dr. Hirsch’s comments
on the MSNJ policy that AMA
membership should be encouraged
but that it should be voluntary.
(6) AMA Physicians’ Assistance
Program . . . Noted that a resolu-
tion is being introduced calling for
the AMA to continue funding and
maintaining an impaired physi-
cians’ program.
(7) AMA Interim Meeting . . .
Unanimously carried the request
to formulate a resolution calling for
the AMA to begin, at an ap-
propriate point, to hold interim
meetings in Washington, DC.
(8) News Media Items . . . Noted
three news items: availability of
copies of Mr. Maressa’s response to
the editorial entitled, “The E.T.
Answer to Doctor Bills”; commen-
dation for the recent MSNJ ad-
vertisement, “Doctor’s Medicare
Fees”; and referred to the Council
on Public Relations a public rela-
tions campaign for the elderly to
have their personal physician re-
view their medications, as done by
Essex County Medical Society.
(9) Immunizations for Children
. . . Requested the Essex County
Medical Society to send their con-
cerns regarding immunization
schedules to the New Jersey
Academy of Pediatrics for review
and report.
(10) AIDS Legislation . . . Re-
ferred a letter from Congressman
William Dannemeyer (seeking en-
dorsement of the Public Health
Response to AIDS Act of 1989 es-
tablishing certain eligibility re-
quirements in the program of
grants to the states for counseling
and testing with respect to AIDS
and for other purposes) to the Task
Force on AIDS for consideration
and report.
(11) AMA Leadership Con-
ferences . . . Noted that ten mem-
bers will attend this Conference to
be held on February 24-26, 1990, in
Phoenix, Arizona.
Report of Executive Director . . ,
(1) MSNJ Paid Memberships
. . . Noted that as of October 1989,
paid memberships were 7,457, and
observed that as the effects of the
special assessment begin to de-
cline, membership again will as-
sume a favorable trend. Also,
noted the list of 314 members who
did not pay the special assessment
will be published in NEW JER-
SEY MEDICINE.
(2) Financial Statements . . . Re-
viewed and approved the financial
statements for the months of Sep-
tember and October 1989.
(3) State Board of Medical
Examiners . . . Noted two signifi-
cant changes in N.J.A.C.
13:34-6.5: if the patient or a subse-
52
NEW JERSEY MEDICINE
quent treating health care pro-
fessional is unable to read the
treatment record, either because it
is illegible or prepared in a
language other than English, the
licensee shall provide a transcrip-
tion at no cost to the patient; and
the licensee shall not refuse to
provide a professional treatment
record on the grounds that the pa-
tient owes the licensee an unpaid
balance, if the record is needed by
another health care professional
for the purpose of rendering care.
(4) Medicare Transition . . .
Filed a request with SBME regard-
ing the refusal of HCFA to honor
SBME’s major surgery rule (defin-
ing a procedure in which an open-
ing is made into any of the major
body cavities as major surgery re-
quiring an assisting physician);
and noted that the Pennsylvania
Blue Shield Provider 800 line will
be discontinued as of December 31,
1989, but MSNJ will submit a re-
quest that the line be re-estab-
lished.
(5) Litigation Reports . . . Re-
viewed the following litigation: in-
terrogatories have been served and
notices of deposition are being
prepared and a case management
conference has been scheduled in
the suit against the insurance com-
missioner over his failure to fund
the Medical Malpractice Re-
insurance Association deficit in a
fair and lawful practice; request
has been Filed with the EPA for a
stay of their fee collection format
(members have been advised to
complete the registration form but
not to pay the fee); heard that
SBME will file a brief challenging
the Board of Physical Therapy in
two areas: the right of the therapist
to examine a patient without a
prior physician referral and the
right of the therapist to alter a
physician prescription without the
physician’s approval; awaiting a
trial date for in re Sinha involving
a medial licensure action; and
MSNJ versus PRO case is pending
in federal district court, and a trial
date in June appears likely.
(6) Membership Directory . . .
Noted that the supplement to the
Directory has been published and
distributed.
Specialty Reports . . . Received
reports from Stanley S. Bergen, Jr,
MD (UMDNJ); Michael B.
Grossman, DO (State Board of
Medical Examiners); and the New
Jersey Hospital Association.
Academy of Medicine of New
Jersey . . . Noted that Dr.
Leighton E. Cluff is the recipient
of the Edward J. Ill Award and
Arline Schwartzman is the recipi-
ent of the Citizen Award for 1990.
Task Force on AIDS . . . Ap-
proved the following recommen-
dations:
That the Board of Trustees submit a
letter to the Governor’s office request-
ing that a strong, centralized inter-
agency task force (with physician
membership) be established to ag-
gressively attack the burgeoning AIDS
epidemic in New Jersey.
That the Medical Society of New Jer-
sey, through the Council on Legis-
lation, develop legislation requiring
compulsory HIV testing and counsel-
ing for all existing prisoners.
Unfinished Business: S-3429 —
Commissioner of Health . . .
Voted to actively oppose S-3429
(this bill deletes the requirement
for a medical license to be held by
the commissioner of health).
New Business: New Jersey
Physicians in Home Care
Awards Program . . . Voted to de-
cline endorsement of this program,
as MSNJ has not specifically en-
dorsed other awards in the past.
Correspondence . . . Received a
letter from David I. Knowlton, act-
ing commissioner of health, re-
sponding to concerns raised by the
Committee on Medical Aspects of
Sports in light of the issue covered
by A-1734 (the bill requires ran-
dom drug testing of school athletes
before participation in events);
and referred the letter addressing
the issue of the need for uniform
criteria among state-certified
utilization review organizations
from Commissioner of Health
Molly Coye to the Committee on
Utilization Review Systems for its
review. □
■Ml UMDNJ NOTES H
The University of Medicine and
Dentistry of New Jersey (UMDNJ)
broke ground October 26 at its
Newark campus for a $55 million
medical office complex and park-
ing garage. The eight-level medical
office complex will allow UMDNJ
to expand clinical services and
educational programs. The build-
ing and adjacent 1,031-car parking
facility will occupy the Bergen
Street- 12th Avenue corner of the
campus.
The medical office complex will
house the faculty practice services
of UMDNJ-New Jersey Medical
School and UMDNJ-New Jersey
Dental School. Some 300 faculty
physicians and dentists will pro-
vide a wide range of health-care
services from the facility.
Designed as a full-service am-
bulatory care facility, the medical
office complex will provide a com-
prehensive array of outpatient ser-
vices including a same-day surgery
center, imaging center, and re-
habilitation unit. In addition, the
complex will consolidate several
services and features on the New-
ark campus, including: quarters
for The Eye Institute of New Jer-
sey; quarters for the Stone Center
of New Jersey, a lithotripsy
(kidney stone therapy) unit run
jointly by UMDNJ and Saint
Barnabas Medical Center, Liv-
ingston, a UMDNJ affiliate; a Uni-
versity Center comprising a con-
ference facility, and dining and fit-
ness centers open to UMDNJ fac-
ulty, staff, and students; the Em-
ployee/Student Health Center;
and space for complementary com-
mercial opportunities, such as a
coffee shop, newsstand, and phar-
VOL. 87— NUMBER 1 JANUARY 1990
53
macy/medical equipment shop.
For the first time, New Jersey
students can receive doctoral level
training in public health without
leaving the state. Doctoral degrees
in public health now are offered
through two new programs jointly
administered by UMDNJ and
Rutgers, the State University of
New Jersey. The doctor of philos-
ophy (PhD) program in public
health is for students interested in
academic careers furthering basic
knowledge and theory on the
health effects of environmental
and occupational conditions. The
doctor of public health (Dr PH)
program trains students to apply
their knowledge to specific prob-
lems such as setting priorities for
cancer research or providing health
services for hazardous substance
workers.
UMDNJ has received a new fed-
eral grant of almost $1.6 million to
launch the state’s first federally
funded regional AIDS Education
and Training Center. One of only
15 in the nation, the Center will
provide comprehensive training
programs consisting of courses and
workshops aimed at all segments of
the health care professions.
The Center is funded by a three-
year $1,586,784 grant from the
Health Resources and Services Ad-
ministration of the Department of
Health and Human Services. Ad-
ministered by UMDNJ’s Office of
Continuing Education, it is an out-
growth of UMDNJ’s Center for
AIDS Education, established in
1988 to centralize education pro-
grams and attract funding to
create a statewide resource.
An innovative peer-mentoring
program to smooth the way for
first-year minority group dental
students has been started at
UMDNJ-New Jersey Dental
School, Newark. This year, 22
black and Hispanic freshmen have
been teamed with upperclass stu-
dent-mentors in the Peer Initiative
Program. The student mentors
guide the freshmen in such areas as
obtaining tutors and working out
study plans for difficult courses.
They also provide general infor-
mation about dental education
and the dental school. The Peer
Initiative Program is believed to be
one of the first of its kind at a den-
tal school in the nation.
Congratulations to: Dr. Donald
Louria, a leading public health ex-
pert at UMDNJ, who received the
major public health award of the
New Jersey Public Health Associa-
tion; and William R. Walsh, Jr,
executive vice-president of finance
and treasurer of the Robert Wood
Johnson Foundation, who received
the 1989 Distinguished Service
Award from the Melvin H.
Motolinsky Research Foundation.
□ Stanley S. Bergen, Jr, MD
1990 MSNJ ANNUAL MEETING
Saturday, May 5, 1990
3:30 p.m. Board of Trustees’ Meeting
7:00 p.m. Officers’ Cocktail Reception and Dinner
Sunday, May 6, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
10:00 a.m. Educational Program
11:00 a.m. Exhibits Open
1:00 p.m. House of Delegates
3:30 p.m. Reference Committee Meetings
Monday, May 7, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates (Election)
12:00 noon Golden Merit Award Ceremony and Reception
1 :00 p.m. Professional Liability Program (MIIENJ)
2:45 p.m. Reference Committee Meetings
5:00 p.m. JEMPAC Political Forum
5:45 p.m. JEMPAC Wine and Cheese Reception
6:30 p.m. Somerset County Medical Society
Tuesday, May 8, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates
1:30 p.m. House of Delegates
2:00 p.m. Exhibits Close
6:30 p.m. Inaugural Reception and Dinner
Wednesday, May 9, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. General Session
1 .00 p.m. Board of Trustees’ Meeting
54
NEW JERSEY MEDICINE
^■MSNJ AUXILIARY M
One of the major accomplish-
ments of the American Medical
Association Auxiliary (AMAA) is
its longstanding commitment to
health education, particularly its
sponsorship of juvenile/adolescent
health and drug abuse programs.
The MSNJ Auxiliary recently
presented a health symposium,
“Protect Their Future.” The
session, attended by educators
from high schools and colleges
across the state, included dis-
cussions on helmet safety, head in-
jury and trauma, and anabolic
steroid abuse.
Barbara Repetti, from the As-
sociation of Retired Citizens in
Union County, and Pat Cone, RN,
from the University of Medicine
and Dentistry of New Jersey, both
addressed the issue of head trauma
caused by bicycle accidents and
the necessity for cyclists of all ages
to wear safety helmets.
According to Mrs. Repetti, a
bicyclist is injured four times each
hour of each day and nearly 1,300
die yearly. Children under 15 years
of age account for 600 of all bicycle
deaths. Of these deaths, 75 percent
are caused by head injury. Bicycle
injuries account for more than one-
half million emergency room vic-
tims. One third of all victims of
bicycling accidents treated in
emergency rooms have head in-
juries, as do two-thirds of all pa-
tients with bicycle injuries ad-
mitted to the hospital. Even in a
minor accident, a child has a
50/50 chance of hitting his head.
Each year 6,000 children are hospi-
talized due to bike-car accidents.
And because bicycle riding is so
popular — 111 million riders in the
United States — injuries are in-
creasing.
Ronald D. Grossman, MD, phy-
sician for the United States Olym-
pic Medical Committee and a
member of the drug testing crew,
and Pat Croce, PT, trainer for the
Philadelphia Flyers and the 76ers,
spoke on anabolic steroid abuse.
Anabolic steroids, derivatives of
the male hormone, testosterone,
increase protein synthesis, which
combined with proper diet and
training, produce an increase in
body mass, lean muscle tissue, and
overall strength.
Dr. Grossman warned the au-
dience that anabolic steroids have
filtered down to junior high, high
school, and college sports. He
emphasized that children must
learn the real and potential risks
involved; for example, anabolic
steroids affect the body’s normal
hormonal balance and cause
dangerous side effects ranging
from impotence and sterility, to
liver cancer, heart disease, psy-
chosis, and death. There also is
pervasive psychological and physi-
cal addiction to anabolic steroids.
Teachers can identify students
using anabolic steroids in several
ways: rapid weight gain — 15 to 30
pounds in one or two months;
development of acne, particularly
on the back; great behavioral
changes — overtly hostile, ready to
explode, even to hurt someone.
Pat Croce continued the dis-
cussion, including information on
the aspects of fitness and the side
effects of steroid use. He cautioned
that using drugs to improve ath-
letic performance undermines one
of the most basic notions of
sports — the value of honesty, hard
work, and discipline. To stop drug
abuse in sports, he emphasized the
need for drug testing, appropriate
education, and laws designating
anabolic steroids as controlled
substances. □ Marion Geib
■■AMNJ UPDATE ■■■
The Board of Trustees of the
Academy of Medicine of New Jer-
sey has named the 1990 recipients
of the awards presented at the
Academy’s Annual Awards Dinner
on Wednesday, May 23, 1990, held
at the Chanticler in Short Hills.
Leighton E. Cluff, MD, of
Princeton, will receive the Edward
J. Ill Award “presented annually
to that physician of New Jersey
who merits recognition by the
Academy for distinguished service
as a leader in the medical pro-
fession.” Recent recipients have
included Drs. James Todd, Arthur
Krosnick, Leon Smith, Alfred
Alessi, Stanley Bergen, Palma For-
mica, Paul Hirsch, Richard Rey-
nolds, Ervin Moss, and James
Oleske.
Dr. Cluff is president of the Rob-
ert Wood Johnson Foundation. His
leadership of that Foundation has
been instrumental in maintaining
and advancing its position of pre-
eminence in the advancement of
the health of this country through
support of highly focused and
imaginative projects. Many of
these projects strike to the very
core of the problems of health care
delivery to underserved popu-
lations and the problems of the in-
terface between the practice of
medicine and the changing social
fabric of our society.
The Academy’s Citizen’s Award
is “presented annually to that
citizen or group of citizens of New
Jersey who merit recognition by
the Academy for distinguished ser-
vice in the interest of the health
and welfare of the community at
large.” The 1990 Citizen’s Award
has been granted to Arline
Schwartzman of Highland Park.
Recent recipients include Richard
J. Hughes, former governor of New
Jersey; Alan Sagner, past-chair-
man of the Port Authority of New
York and New Jersey; Drs.
Herman and Anne Somers; Con-
gressman James Courter; Malcolm
Borg, publisher of the Bergen Rec-
ord; Mary Strong of the Citizens’
Committee on Biomedical Ethics;
Assemblyman Chuck Hardwick;
and attorney Paul Armstrong.
Mrs. Schwartzman exhibits the
spirit of effective volunteerism.
She has served as president of the
Auxiliary of the Robert Wood
Johnson University Hospital and
has served on their Board of
Trustees (and its predecessor)
since 1965. For the past five years,
VOL. 87— NUMBER 1 JANUARY 1990
55
she has been the chairperson of the
Professional Affairs Committee
which has dealt with all aspects of
medicine, ethics, and the regu-
lation of hospital practice. She is
truly dedicated to making New
Jersey a better place to live for its
residents and giving those resi-
dents a better chance to be
healthy.
We are pleased to announce that
Lewis Coriell, MD, a member of
the Medical Society of New Jersey,
was selected by an academy of
prestigious New Jerseyans to re-
ceive the Clara Barton Medical
Service Award. The award was
presented at the Fourth Annual
Governor’s Jersey Pride Awards
Program held on Thursday, Janu-
ary 4, 1990, at Princeton’s
McCarter Theatre. The award is
sponsored by the Academy and the
American Red Cross. This project
is part of a major statewide effort
by Governor Kean to improve the
image of New Jersey and to rec-
ognize New Jerseyans who have ac-
complished many great and im-
portant advances in a wide variety
of fields. A total of 11 specific fields
was recognized at the formal cere-
mony. □ Frederick B. Cohen, MD,
President
I LEGISLATIVE BULLETIN!
The accompanying list presents,
for your information and reference,
the official position of the Medical
Society of New Jersey regarding
bills currently in the Legislature.
As further bills of medical interest
are introduced, they will be con-
sidered by the Society and sup-
plemental bulletins will be sup-
plied, indicating the Society’s po-
sition.
Positions. The Society has
adopted the following regular
range of official positions concern-
ing proposed legislation:
ACTIVE SUPPORT: All out
support for the measure.
ACTIVE OPPOSITION: All
out opposition for the measure.
CONDITIONAL APPROV-
AL: To indicate that the approval
of the Society is conditional, sub-
ject to elimination of the un-
satisfactory elements of the bill
that are pointed out.
APPROVAL: Commended as
satisfactory, but not actively sup-
ported.
DISAPPROVAL: Rejected as
unsatisfactory, but not actively op-
posed.
NO ACTION: Considered, but
not regarded as significant or rel-
evant to the proper interest of the
Society.
Senate/Assembly (Active)
S-722-Codey — Mental Health Cov-
erage. Requires health insurers (hospi-
tal service corporations) to provide
coverage for mental illnesses. Active
Support.
S-723-Codey — Mental Health Cov-
erage. Requires health insurers (medi-
cal service corporations) to provide
coverage for mental illnesses. Active
Support.
S-724-Codey — Mental Health Cov-
erage. Requires health insurers (com-
mercial group health) to provide cov-
erage for mental illnesses. Active Sup-
port.
S-725-Codey — Mental Health Cov-
erage. Requires health insurers (com-
mercial individual health) to provide
coverage for mental illnesses. Active
Support.
S-726-Codey — Mental Health Cov-
erage. Requires health insurers
(HMOs) to provide coverage for men-
tal illnesses. Active Support.
S-727-Codey — Mental Health Cov-
erage. Requires health insurers
(health service corporations) to
provide coverage for mental illnesses.
Active Support.
S-3440-Codey — Generic Substitu-
tion/Prescription Blank Change.
Changes prescription forms to facili-
tate use of generic drugs. Active Op-
position, filling out the new prescrip-
tion format would require more time
for physicians, the probability of for-
getting to write the required words to
override generics was greater when
using a blank form and, therefore, the
new format would not be in the best
interest of patients.
S-3494-Zane — Unemployment
Compensation and Disability Ben-
efits. Exempts physicians who are in-
dependent contractors from employ-
ment and disability taxes. Clarifies an
ambiguity in the current law. Active
Support.
S-3549-Lynch — Optometric Use of
Drugs. Permits optometrists to use
drugs for diagnostic and treatment
purposes. Active Opposition, op-
tometrists are not medical doctors and,
therefore, should not be given the man-
date, via legislation, to administer
drugs. If the wrong medication is
prescribed, what appears to be a
simple problem could develop into a
destructive process of the eye in a very
short period of time. The bill is short-
sighted in attempting to provide less
expensive care to the general public to
the detriment of their health.
A-4259-Naples — Medical Records.
Would require that records be
“furnished upon request to the patient
and/or his duly authorized representa-
tive immediately.” Active Opposi-
tion, this situation is adequately cov-
ered under existing regulation and
could not be implemented in the form
stated in the bill.
Senate/Assembly (Monitor)
S-2939-Van Wagner — Emergency
Services. Appropriates $1.5 million to
the Department of Health to be used
for EMS training and equipment. Ap-
proved.
S-3104-Lipman — AIDS. Makes
AIDS or HIV sensitivity reportable to
the Department of Health and
provides for confidentiality. Action
Deferred, pending review of the Task
Force on AIDS of the Assembly
amendments to S-3104.
S-3236-Rice — AIDS. Requires that
persons convicted for using controlled
dangerous substances shall be tested
for AIDS and HIV sensitivity. Action
Deferred, pending reconsideration of
the Task Force on AIDS about this
legislation.
S-3261-Bassano — Drug Testing
Student Athletes. Requires school
boards to establish random drug test-
ing programs for student athletes. Tes-
ting would be done at school board ex-
pense. Disapproved, the issue of drug
abuse in the school extends beyond the
scope of the student athlete. This bill
therefore, would send the wrong
message and ignore the need to
educate and test beyond the athlete
population.
56
NEW JERSEY MEDICINE
S-3320-Ambrosio — Health Care
Directives. Establishes procedures for
the execution of advance directives for
health care. The advance directives in-
volve designation of a health care rep-
resentative and a statement of per-
sonal wishes in the event of loss of de-
cision-making capacity. Action De-
ferred, pending review of the Senate
Committee amendments by the Com-
mittee on Biomedial Ethics.
S-3327-Codey — Infection Control
Education. Requires institutions
which educate allied health pro-
fessionals to incorporate infection pre-
vention and control as part of their
program. No Action.
S-3346-Codey — Laboratory Direc-
tor’s Licensing. Adds “diagnostic lab-
oratory immunology” to the list of
specialty licenses. No Action.
S-3389-Paterniti — Health Needs
Study (same as A-2987). Requires the
commissioner of health to conduct a
study of the health needs of low income
persons over the age of 60. Disap-
proved, this study is unnecessary;
there is a wealth of information on this
topic available through federal and
academic sources.
S-3429-Ewing — Commissioner of
Health (same as A-4142). Deletes the
requirement of a medical license to be
commissioner of health. Conditional
Approval, pending amendment of the
bill to create a position of physician
general and also to include an MSNJ
representative on the Health Care Ad-
ministration Board.
S-3433-D’Amico — Medical Waste.
Increases the categories of regulated
medical waste to include — wastes from
surgery or autopsy that were in contact
with infectious agents, including soiled
dressings, sponges, drapes, lavage
tubes, drainage sets, underpads, and
surgical gloves; laboratory wastes from
medical, pathological, pharma-
ceutical, or other research, com-
mercial, or industrial laboratories that
were in contact with infectious agents,
including slides and cover slips, dis-
posable gloves, laboratory coats, and
aprons; dialysis wastes that were in
contact with the blood of patients
undergoing hemodialysis, including
contaminated disposable equipment
and supplies such as tubing, filters,
disposable sheets, towels, gloves,
aprons, and laboratory coats; dis-
carded medical equipment and parts
that were in contact with infectious
agents; biological waste and discarded
materials contaminated with blood,
excretion, exudates, or secretion from
human beings or animals who are
isolated to protect others from com-
municable diseases. Disapproved, w/
Active Opposition if the bill moves,
until the current law is effectively im-
plemented.
S-3463-Contillo — HIV Testing for
Certain Defendants. Mandates HIV
testing when any criminal commits an
offense that results in a victim or third
party exchanging body fluids or a nee-
dle stick if there is probable cause to
believe the defendant is an IV drug
user. Action Deferred, pending
further information from the Task
Force on AIDS with the following rec-
ommendation that the bill be amended
to read “that any person who is
charged with a criminal offense that
results in the victim or a third party
exchanging body fluids should be
tested for HIV positivity.”
S-3479-Zimmer — Hospital Un-
compensated Care Charges. Requires
hospitals to itemize uncompensated
care costs on patient bills. No Action.
S-3546-Feldman — Sexually
Abused Children. Requires the com-
missioner of human services to estab-
lish two regional treatment centers for
sexually abused children. The regional
centers would be networked into com-
munity-based model programs and a
research institute at one of the schools
of higher education. No Action.
S-3565-Ewing — HIV Testing of
Newborns. Requires that all newborns
be tested for HIV sensitivity. Action
Deferred, pending further information
from the Task Force on AIDS with the
following recommendations: 1. Con-
sider HIV testing of mother. 2. Con-
sider the possibility of HIV testing of
all prenatal patients. 3. Consider false
negative and false positive readings
and what should be done in these in-
stances.
A-955-Kern — Artificial Insemina-
tion. Statutorily regulates artificial in-
semination, requires certain forms of
consent, data gathering, and record-
keeping. No Action, the Council
directed that correspondence be ad-
dressed to the sponsor of the bill rec-
ommending that it be written in con-
formance with the American Fertility
Society Guidelines.
A-1456-Kline — Organ Trans-
plants. Prohibits organ transplants
unless the tissues are HIV negative.
Approved.
A-2938-Ogden — Communicable
Disease. Requires health care facili-
ties to notify first aid, ambulance, or
rescue squads that the patient they are
transporting has a communicable dis-
ease when that fact is known to the
facility. Approved.
A-2987-Lobiondo — Health Needs
Study (same as S-3389). Requires the
commissioner of health to conduct a
study of the health needs of low-in-
come persons over the age of 60. Dis-
approved, this study is unnecessary;
there is a wealth of information on this
topic available through federal and
academic sources.
A-3804-Littell — Ambulance, Fire,
Rescue Squads. Prohibits the forma-
tion of local, regional, or statewide
EMS coordinating areas. Approved.
A-4224-Girgenti — Anabolic Ster-
iods. Makes it a crime to dispense ster-
oids without a prescription to minors;
requires the commissioner of health to
conduct studies to determine whether
anabolic steroids should become
scheduled drugs. Conditional Ap-
proval, pending deletion of the words
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
VOL. 87— NUMBER 1 JANUARY 1990
57
“to minors,” making it a crime to dis-
pense steroids without a prescription.
Also, pending notification that
anabolic steriods will not be added to
the controlled schedule II listing.
A-4226-Bush — Fetal Alcohol Syn-
drome (FAS) (same as S-3149). Re-
quires retail establishments (alcohol)
to post warnings about alcohol con-
sumption during pregnancy. Ap-
proved.
A-4255-Palaia — Tanning Salons
(same as S-1554). Requires the De-
partment of Health to establish safety
standards for tanning facilities that
shall be enforced through the local
board of health. Approved.
A-4284-Impreveduto — Chiroprac-
tic Board. Creates a separate Board of
Chiropractic Examiners and transfers
all current rules to the new board. No
Action.
A-4299-Kline — HIV Testing New-
borns. Requires that all newborns be
tested for HIV sensitivity under De-
partment of Health guidelines. Action
Deferred, pending further information
from the Task Force on AIDS with the
following recommendations: 1. Con-
sider HIV testing of mother; 2. con-
sider the possibility of HIV testing of
all prenatal patients; 3. consider false
negative and false positive readings
and what should be done in these in-
stances.
A-4321 -Cooper — HIB. Requires the
Department of Health to distribute in-
formation to physicians on HIB vac-
cine. No Action.
A-4382-Karcher — Video Ter-
minals in Workplace. An employer
shall make available to an operator an
annual eye and vision examination
that conforms to the recommended
components of an eye and vision exam-
ination established by the American
Optometric Association, with con-
sideration given to the specific require-
ments of visual correction that may be
needed by an operator. No Action.
A-4453-Smith — HIV Positive Psy-
chiatric Patients. Provides that pa-
tients who are in state psychiatric fa-
cilities and are HIV positive are to be
isolated in accordance with policies ap-
proved by the commissioner of human
services and the commissioner of
health. Action Deferred, pending
further information from the Task
Force on AIDS, the Council on Mental
Health, and the New Jersey Psy-
chiatric Association.
,
A-4536-Randall — Health Care
Directives. Establishes procedures for
the execution of advanced directives
for health care. The advance directives
involve designation of a health care
representative and a statement of per-
sonal wishes in the event of loss of de-
cision-making capacity. Action De-
ferred, pending further information
from the Committee on Biomedical
Ethics.
A-4560-Franks — Motor Vehicle
Drivers — Drug Testing. Requires the
Division of Motor Vehicles to establish
a three-year random sample drug test-
ing program for applicants for a driv-
er’s license. Disapproved, the cost of
this legislation would make implemen-
tation of the bill very difficult.
A-457 6-McEnroe — Graduate
Medical Education. Adds the dean of
the School of Graduate Medical
Education at Seton Hall to the Ad-
visory Council on Graduate Medical
Education. No Action.
A-4577- Villa piano— Emergency
Medical Transportation Services.
Requires the Department of Health to
notify county health departments of all
persons residing in the county that are
HIV positive. The county health de-
partment is to pass the list on to each
EMS transport provider. A similar no-
tice by hospitals is to be given to EMS
transport when an HIV positive pa-
tient is leaving that hospital by EMS
transport. Disapproved, unen-
forceable, unworkable legislation.
A-4683-Zecker— HMO— Medicare.
Requires HMOs that offer services to
Medicare recipients to provide sup-
plemental coverage in accordance with
the Federal Catastrophic Coverage
Act. No Action.
A-4684-Zecker — Medicare — Medi-
cal, Hospital, and Service Corpora-
tion. Same as A-4683; applies to Blue
Cross and Blue Shield. No Action.
A-4685-Zecker — Medicare —
Health Insurers. Same as A-4683 ap-
plies to health insurers. No Action.
□ June O’Hare
Hi PLACEMENT FILE Hi
The following physicians have
written to the Executive Offices of
MSNJ seeking information on
possible opportunities for practice
in New Jersey. The information
listed below has been supplied by
the physicians. If you are inter-
ested in any further information
concerning these physicians, we
suggest you make inquiries directly
to them.
ANESTHESIOLOGY
Hak Joo Cha, MD, 22 Hamilton Ct.,
Lawrenceville, NJ 08648. Catholic
Medical College 1972. Board eligible.
Solo, partnership, group, fee-for-ser-
vice. Available.
CARDIOLOGY
Fredric Gerewitz, MD, 125 Montgom-
ery Ave., Bala Cynwyd, PA 19004.
SUNY-Downstate 1984. Board eligi-
ble. Group or partnership. Available
July 1990.
Matilda M. Taddeo, MD, 2269 Ellis
Ave., Bronx, NY 10462. West Indies
1983. Board eligible. Group, partner-
ship. Available.
GASTROENTEROLOGY
Eric Avezzano, MD, 2510 B.S. Walter
Reed Dr., Arlington, VA 22206. SUNY-
Stonv Brook 1985. Board eligible;
board certified (IM). Group, partner-
ship, solo. Available July 1990.
David L. Fishkin, MD, 1000J Scaife
Hall, University of Pittsburgh, Pitts-
burgh, PA 15261. SUNY-Downstate
1985. Board eligible. Board certified
(IM). Group, partnership, solo. Avail-
able July 1990.
INTERNAL MEDICINE
Albert S. Ford, MD, 943 Norway Ave.,
Huntington, WV 25703. Meharry
Medical College 1982. Board eligible.
Solo; practice purchase. Available
June 1990.
Himanshu Shah, MD, 71 Louis St.,
New Brunswick, NJ 08901. UMDNJ
1988. Part-time position. Available.
NUCLEAR MEDICINE
Robert W. Cifers, MD, 26 Somers
Ave., Seaville, NJ 08230. Ohio State
1983. Board eligible. Available.
OTOLARYNGOLOGY
Samuel H. Selesnick, MD, 450 East
63rd St., #8F, New York, NY 10021.
NYU 1985. Board eligible. Available
July 1990.
PATHOLOGY
Ruth Kreitzer-Richards, MD, 5470
Mosholu Ave., Riverdale, NY 10471.
Guadalajara 1983. Board certified.
Available July 1990.
58
NEW JERSEY MEDICINE
CONTINUING EDUCATION
ANESTHESIOLOGY
March
24- Annual Postgraduate
25 Anesthesia Seminar
All day — The Hyatt, Cherry Hill
( New Jersey State Society of
Anesthesiologists)
CARDIOLOGY
February
21 Anti-Arrhythmic Therapy
10:30-11:30 P.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
March
14 Advanced Cardiac Life Support
21 All day — Freehold Area Hospital,
Freehold
( Freehold Area Hospital)
DERMATOLOGY
February
21 Robert Wood Johnson Medical
School Dermatological
Conferences
6-9 P.M. — Rutgers Community
Health Plan, US #1,
New Brunswick
(UMDNJ)
March
21 Robert Wood Johnson Medical
School Dermatological
Conferences
6-9 P.M. — Rutgers Community
Health Plan, US § 1 ,
New Brunswick
(UMDNJ)
INFECTIOUS DISEASE
February
6 Counseling and Testing for HIV
Infection
12 Noon-1 P.M. — The Hospital
Center at Orange, Orange
(AMNJ and NJDOH)
12 Counseling and Testing for HIV
Infection
12 Noon-1 P.M. — East Orange
General Hospital, East Orange
(AMNJ and NJDOH)
28 Counseling and Testing for HIV
Infection
11:30 A. M. -12:30 P.M. — Hamilton
Hospital, Hamilton
(AMNJ and NJDOH)
28 Clinical Management of HIV
Infection
1:30-2:30 P.M. — Trenton
Psychiatric Hospital,
Trenton
(AMNJ and NJDOH)
MEDICINE
February
1 Adrenal Disease
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
2 Update on Antibiotic Therapy
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
2 Continuing Medical Education
9 Program
16 12 Noon-1 P.M. — United Hospitals
23 Medical Center, Newark
(United Hospitals Medical
Center)
7 Winter Dinner Meeting
6:30 P.M. — The Hilton at Short
Hills, Short Hills
(New Jersey Gastroenterological
Society)
7 Medical Lecture Series
14 10:30-11:30 A. M— Christ
21 Hospital, Jersey City
28 (Christ Hospital)
7 Internal Medicine
14 Review Course
21 4-7 P.M. — University Hospital,
28 New Brunswick
(AMNJ and UMDNJ)
7 Urinary Incontinence of the
Elderly
2-3 P.M. — John E. Runnells
Hospital of Union County,
Berkeley Heights
(AMNJ)
8 Update on Geriatric Medicine
22 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
9 How Healthcare Professionals
Can Protect Themselves from
Frivolous Lawsuits
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
12 Fluid and Electrolyte Imbalance
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
14 Dialogues in Critical Medical
Decisions
7:30-9 P.M. — Englewood Hospital,
Englewood
(Englewood Hospital)
15 Continuing Medical Education
12 Noon — Somerset Medical
Center, Somerville
(Somerset Medical Center)
1 6 Role of NSAIDs in the Geriatric
Population
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
17 Morbidity and Mortality
24 Conference
8:30-10 A.M. — New Jersey
Medical School, Newark
(UMDNJ)
16 Current Clinical Concepts in
Rheumatology/Immunology:
Acute Phase Reactants
12:15-1:15 P.M. — Kennedy
Memorial Hospital, Stratford
(UMDNJ/ Kennedy Memorial
Hospital)
21 Dually Diagnosed
2:30-3:30 P.M. —Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
22 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
23 Diabetic Nephropathy
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
March
1 Colitis
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
VOL. 87— NUMBER 1 JANUARY 1990
61
Hahnemann University
Department of Medicine
JANUARY 1990
January 3, 1990
PROGRESSIVE MULTIFOCAL
LEUKOENCEPHALOPATHY
Elliott L. Mancall, M.D.
Professor and Chairman
Department of Neurology
Hahnemann University
January 10, 1990
SODIUM SENSITIVITY & RESISTANCE
OF BLOOD PRESSURE
Myron H. Weinberger, M.D.
Professor of Medicine
Director, Hypertension Research Center
Indiana University School of Medicine
Indianapolis, IN
January 17, 1990
RHEUMATOLOGY & IMMUNOLOGY: NEWER
ADVANCES
Rapheal J. DeHoratlus, M.D.
Professor of Medicine
Director, Division of Clinical Immunology and
Rheumatology
Hahnemann University
January 24, 1990
SKIN CANCER (Non-melanoma)
Gary R. Kantor, M.D.
Associate Professor of Medicine and Dermatology
Department of Medicine
Hahnemann University
January 31, 1990
SPACE MEDICINE: CARDIOVASCULAR, BONE,
FLUID SHIFTS AFFECTS OF SPACE
G. John DIGregorlo, M.D., Ph.D.
Professor of Pharmacology and Medicine
Director, Division of Toxicology
Consultant to N.A.S.A.
Hahnemann University
WEDNESDAYS GRAND ROUNDS
8:30 A.M.-9:30 A.M.
Januaiy-May 1990
FEBRUARY 1990
February 7, 1990
SOMATOSTATIN, CARCINOID SYNDROME
John Oates, M.D.
Professor & Chairman
Department of Medicine
Vanderbilt University
Nashville, TN
February 14, 1990
LYME DISEASE
Steven Blllsteln, M.D., MPH
Associate Professor of Medicine
Columbia Presbyterian Medical Center
New York, NY
February 21, 1990
NEOPLASTIC DISEASE ADVANCES
IN THERAPY
Isadora Brodsky, M.D.
Professor and Chairman
Department of Neoplastic Diseases
Director, Institute of Cancer & Blood Diseases
Hahnemann University
February 29, 1990
CLINICAL PATHOLOGIC CONFERENCE
Chief Residents:
Michael DeAngells, M.D.
Ana Nunez, M.D.
Ralph McKIbben, M.D
Matthew Sandler, M O.
MARCH 1990
March 7, 1990
IMMUNE INTERVENTION IN TYPE I DIABETES
MELLITUS
Jay S. Skylar, M.D.
Professor of Medicine
Director, Diabetes Mellltus
University of Miami
Miami, FL
March 14, 1990
COPD: PATHOGENESIS AND TREATMENT
ADVANCES
Mark J. Utell, M.D.
Professor of Medicine and Toxicology
University of Rochester
Rochester, NY
March 21, 1990
CLINICAL PHARMACOLOGY
Vincent J. Zarro, M.D., Ph.D.
Associate Professor of Pharmacology & Medicine
Director, Division of Clinical Pharmacology
Hahnemann University
March 28, 1990
DERMATOLOGIC TREATMENT WITH RETINOIDS
AND CYCLOSPORINE
Richard L. Splelvogel, M.D.
Professor of Medicine and Dermatology
Director, Division of Dermatology
Hahnemann University
JANUARY 10, 1990
WEDNESDAYS
MEDICAL SEMINAR SERIES
8:30 A.M.-3:00 P.M.
MARCH 7, 1990
MARCH 28, 1990
Hypertension: Sodium, Catechols, CNS
Diabetes Mellitus: Immune Mechanisms &
Dermatology: Treatment with Retinoids
Geriatrics
Insulin Therapy Innovations
and Cyclosporine
Hahnemann University Faculty
Hahnemann University Faculty
Hahnemann University Faculty
Allan B. Schwartz, M.D.
Jeffrey L. Miller, M.D
Richard L. Spielvogel, M.D.
Charles Swartz, M.D.
Leslie 1. Rose, M.D.
Eric C. Vonderheid, M.D.
Guest Faculty
Guest Faculty
Gary R. Kantor, M.D.
Myron Weinberger, M.D.
Jay S. Skylar, M.D.
Guest Faculty
University of Indiana School of Medicine
University of Miami
Cynthia Guzzo, M.D.
Carl Engelman, M.D.
Robert Tannenberg, M.D.
University of Pennsylvania
University of Pennsylvania
Georgetown University
Henry H. Roenigk, M.D.
School of Medicine
Northwestern University
Presented by:
William S. Frankl, M.D.
Professor of Medicine and Chairman
Department of Medicine
Allan B. Schwartz, M.D.
Professor of Medicine and
Director, Continuing Medical Education
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd Floor— College Bldg.
Hahnemann University
15th Street Entrance
15th and Vine Streets
Philadelphia, PA
We wish to acknowledge educational support from:
E.R Squibb 8 Sons
Merck, Sharpe & Dohme
Burroughs Wellcome & Co.
Squibb-Novo
Sandoz
Roche
CIBA-Geigy
Approved for CME credits through the Office of Continuing Education, Hahnemann University
For further information: (215) 448-8263
62
NEW JERSEY MEDICINE
2 Continuing Medical
9 Education Program
16 12 Noon-1 P.M. — South Jersey
23 Hospital System, Bridgeton
30 ( South Jersey Hospital System)
7 Internal Medicine
14 Review Course
21 4-7 P.M. — University Hospital,
28 New Brunswick
(AMNJ and UMDNJ)
7 Diabetes-Related Kidney
Disease
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ and NJDOH)
7 Prevention of Lower Extremity
Amputations
11:30 A.M. -12:30 P.M. —Rahway
Hospital, Rahway
(AMNJ)
7 Medical Lecture Series
14 10:30-11:30 A.M.— Christ
21 Hospital, Jersey City
28 ( Christ Hospital)
8- Annual Meeting and Scientific
11 Assembly, New Jersey Academy
of Family Physicians
Caesar’s Palace, Atlantic City
(NJ Academy of Family
Physicians)
8 Update on Geriatric Medicine
22 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
9 Alcoholism
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
9 Functional Assessment of the
Elderly
10:30-11:30 A. M— Christ
Hospital, Jersey City
(AMNJ)
9 Rheumatology Case
Presentation Conference
12:15-1:15 P.M. — Kennedy
Memorial Hospital, Stratford
(UMDNJ /Kennedy Memorial
Hospital)
12 Thyroid Disease
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
13 Renal Biopsy Conference
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
14 Dialogues in Critical Medical
Decisions
7:30-9 P.M. — Englewood Hospital,
Englewood
(Englewood Hospital)
14 Diabetes-Related Kidney
Disease
11:30-A.M. -12:30 P.M. — Rahway
Hospital, Rahway
(AMNJ and NJDOH)
14 Chronic EBV Virus
10:30-11:30 A.M. — University
Hospital, New Brunswick
(AMNJ)
15 Diabetes-Related Kidney
Disease
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
15 Aspiration Syndrome in the
Mentally Retarded
1:30-2:30 P.M. — Vineland
Developmental Center, Vineland
(AMNJ)
15 Continuing Medical Education
Series
12 Noon — Somerset Medical
Center, Somerville
(Somerset Medical Center)
16 Management of Abdominal
Emergencies
1-2 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
17- Annual Meeting, American
18 College of Emergency
Physicians
All day — Trump Plaza Hotel &
Casino, Atlantic City
(American College of Emergency
Physicians)
17 Morbidity and Mortality
24 Conference
8:30-10 A.M. — New Jersey
Medical School, Newark
(UMDNJ)
20 Renal Adaptation to Ventilatory
Response to Metabolic Acid-
Base Disorders
6:30-9:30 A.M. — Overlook
Hospital, Overlook
(AMNJ)
21 Retinopathy
11:30 A.M. -12:30 P.M. —Rahway
Hospital, Rahway
(AMNJ)
22 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
30 Clinicopathologic Case
Presentation
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
OBSTETRICS AND GYNECOLOGY
February
14 Prematurity, Postmaturity, and
Dysmaturity
10:30-11:30 A. M.— St. Mary’s
Hospital, Passaic
(AMNJ)
14 Diabetes in Pregnancy
12 Noon-1 P.M. — St. James
Hospital, Newark
(AMNJ)
March
9- Annual Semmelweiss-Waters
1 1 Ob/Gyn Conference
8 A.M. -5 P.M. — Bally’s Grand
Hotel, Atlantic City
(AMNJ)
ONCOLOGY
February
9 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
14 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
22 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
March
9 Tumor Board Meeting
224th ANNUAL MEETING
MEDICAL SOCIETY OF NEW JERSEY
May 6-9, 1990
The Sands Hotel, Casino & Country Club
Atlantic City
Claridge Casino Hotel
Atlantic City
VOL. 87— NUMBER 1 JANUARY 1990
63
June 11-15, 1990
Update Your Medicine 1990.
Cornell University Medical College and Association of
Practicing Physicians of the New York Hospital. 36’/2
hour Category I credit (42 if optional workshops are
taken). One week review of all subspecialties of internal
medicine. Nine major two-hour symposia, six hour re-
view lectures, and Medical Grand Rounds. Four work-
shops will be given for practical problems and manage-
ment techniques. Optional workshop sessions on
Breast/Pelvic and Male Genitorectal examinations.
Held at the New York Hospital-Cornell, 1300 York Av-
enue at 69th Street, New York, Information: Office of
CME, 212-746-4752, or write Room D-115. Dr. Lila
Wallis is Course Director.
16
INTERNATIONAL CONFERENCES11
1990 CME CRUISE/CONFERENCES ON MEDI-
COLEGAL ISSUES AND SELECTED MEDICAL
TOPICS— Caribbean, Bermuda, Alaska/Canada, New
England, Scandinavia, W. Mediterranean, Europe, Asia,
Trans Panama Canal. Approved for 20-28 CME Cat-
egory 1 Credits (AMA/PRA) and AAFP prescribed
credits. Distinguished lecturers. Excellent group fares
on finest ships. Pre-scheduled in compliance with IRS
requirements. Information: International Con-
ferences, 1290 Weston Road, Suite 316, Ft.
Lauderdale, FL 33326. (800) 521-0076 or (305)
384-6656.
ATTENTION PRIMARY
CARE PHYSICIANS
— Increase Your Skills —
Attend The ULTIMATE Course
in Procedural Skills
LEARN: Allergy testing, audiometry, cryosurgery,
flexible sigmoidoscopy, holter monitoring, naso-
pharyngoscopy, pulmonary function testing,
vasculary flow testing, screening colposcopy,
cardiac stress testing, dermatologic surgery tech-
niques & MORE . . . including appropriate CPT
coding.
Accredited:
16 hours CME (AAFP, AMA, AOA)
Tuition: $395
LOCATIONS— DATES
Houston, TX Feb. 24-25
Atlantic City, NJ .... Mar. 24-25
San Juan, PR* May 5-6
Seattle, WA* June 2-3
Denver, CO July 7-8
*Pre/Post Seminar CRUISE offered.
Sponsored by:
University of South Florida
School of Medicine
Presented by:
CURRENT CONCEPT SEMINARS
America’s Largest Independent Producer
of CME Programs
5700 Stirling Road, Hollywood, FL 33021
(305) 966-1009 • (800) 969-1009
VACATION SEMINARS
— Fully Accredited —
Medical Malpractice
"Damage Control" and
AIDS: An Overview
(Satisfies Relicensure Requirements)
2-5 Day Programs
Offered WEEKLY At:
4 CLUB MED VILLAGES
(Dom. Rep., FL, Mex., Nassau)
DISNEY WORLD*, CRESTED BUTTE (CO)
LAKE PLACID, LAKE TAHOE
MIAMI BEACH, N. CONWAY (NH)
PHOENIX, POCONO MTS. (PA)
SAN DIEGO, STEAMBOAT SPRINGS (CO),
& a DUDE RANCH (AR)
*3 & 4 day Bahamas Cruises
offered (special rate)
Registration fee: $125-225
(8-20 hours CME)
Spouse Free
Presented by:
CURRENT CONCEPT SEMINARS
America’s Largest Independent
Producer of CME Programs
5700 Stirling Road, Hollywood, FL 33021
(305) 966-1009 • (800) 969-1009
NEW JERSEY MEDICINE
64
11 A.M.-12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
14 Tumor Board Conference
11 A.M.-12 Noon — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
22 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
28 Dinner Meeting
6:30-9:30 P.M. — The Hyatt,
New Brunswick
(Radiation Oncology Section-
AMNJ)
PEDIATRICS
February
1 Pediatric Grand Rounds
8 8:30-9:30 A.M. — Robert Wood
15 Johnson Medical School, MEB,
22 102, New Brunswick
(UMDNJ)
22 Update in Aspects of Pediatrics
Marriott Hotel, Saddle Brook
(Northern NJ Pediatric Society)
27 Update in Ribavirin Therapy
12 Noon-1 P.M. — Newark Beth
Israel Medical Center, Newark
(Newark Beth Israel Medical
Center)
March
1 Pediatric Grand Rounds
8 8:30-9:30 A.M. — Robert Wood
15 Johnson Medical School, MEB,
22 102, New Brunswick
29 (UMDNJ)
22 Update in Aspects of Pediatrics
Marriott Hotel, Saddle Brook
(Northern NJ Pediatric Society)
PSYCHIATRY
February
1 Case Seminars To Improve
15 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
6 Anxiety Disorders
10-11 A.M. — Green Brook
Regional Center, Green Brook
(AMNJ)
7 Medical Aspects of Behavior
Management
10-11 A.M. — Johnstone Training
and Research Center, Bordentown
(AMNJ)
March
1 Case Seminars To Improve
15 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
16 Teenage Suicide
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
PULMONOLOGY
March
2 18th Annual Joint Conference
New Jersey Thoracic Society/
New Jersey Chapter of the
American College of Chest
Physicians
Hyatt Regency, New Brunswick
(New Jersey Thoracic Society)
RADIOLOGY
February
7 Ultrasound
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
( St. Mary s Hospital)
15 1989 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of
New Jersey-Diagnostic Section,
AMNJ)
22 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
March
15 1989 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of
New Jersey-Diagnostic Section,
AMNJ)
22 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
31 Seeing the Unseen: Noninvasive
Vascular Imaging in the 90s
8 A.M. -4 P.M. — The Ramada
Renaissance, East Brunswick
(AMNJ)
SURGERY AND ITS SPECIALTIES
February
4 Surgical Treatment of
Cardiothoracic Disease
10-11:30 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
6 Weekly Vascular Case
13 Conference
20 7:30-8:30 A.M. — Robert Wood
27 Johnson Medical School, MEB,
108B, New Brunswick
(UMDNJ)
17 Morbidity and Mortality
24 Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
27 Englewood Surgical Society
Lecture Series
8-10 P.M. — Englewood Club
(Englewood Surgical Society)
28 Journal Club, Section of
Cardiothoracic Surgery
6:30-9:30 P.M. — 2 Mountain
Ridge Drive, Livingston
(UMDNJ)
March
4 Surgical Treatment of
Cardiothoracic Disease
10-11:30 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
6 Weekly Vascular Case
13 Conference
20 7:30-8:30 A.M. — Robert Wood
27 Johnson Medical School, MEB,
108B, New Brunswick
(UMDNJ)
17 Morbidity and Mortality
24 Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
27 Englewood Surgical Society
Lecture Series
8-10 P.M. — The Englewood Club,
Englewood
(Englewood Surgical Society)
28 Journal Club, Section of
Cardiothoracic Surgery
6:30-9:30 P.M. — 2 Mountain
Ridge Drive, Livingston
(UMDNJ)
UROLOGY
February
2 Urology Grand Rounds
9 New Jersey Medical School,
16 MSB, C600, Newark
23 (UMDNJ)
March
2 Urology Grand Rounds
9 New Jersey Medical School,
16 MSB, C600, Newark
23 (UMDNJ)
30
21 Urinary Tract Infection
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
VOL. 87— NUMBER 1 JANUARY 1990
65
IN MEMORIAM
Arthur F. Ackerman. A retired
member of our Union County com-
ponent, Arthur Fowler Ackerman,
MD, died on August 20, 1989. Born
in 1903 in Passaic, Dr. Ackerman
earned his medical degree at Col-
umbia University College of Phy-
sicians and Surgeons, New York,
in 1927; he was awarded his New
Jersey license in 1930. A pedia-
trician, Dr. Ackerman was af-
filiated with Overlook Hospital,
Summit, and Babies Hospital,
New York. Dr. Ackerman was a
member of the American Academy
of Pediatrics and of the American
Medical Association, and was a
diplomate of the American Board
of Pediatrics.
Frank R. Begen. Past-presi-
dent Frank Robert Begen, MD,
died on October 15, 1989, at the
age of 63. Dr. Begen served as
president of the Medical Society of
New Jersey in 1977 and was an ac-
tive fellow of the Society. Born in
1926 in Jersey City, Dr. Begen was
a graduate of Princeton University.
He was awarded a medical degree
from New York Medical College in
1949. Dr. Begen served his in-
ternship at Holy Name Hospital,
Teaneck, and his residency at St.
Claire’s Hospital, New York City.
A Bergen County urologist, Dr.
Begen was affiliated with Holy
Name Hospital, Bergen Pines Hos-
pital, Paramus, and Riverside
General Hospital, Secaucus. A
member of the American Medical
Association, of our Bergen County
component, and of the Academy of
Medicine of New Jersey, Dr. Begen
served on the Cresskill board of
education and was an Air Force
physician.
Selig L. Brauer. Retired Jersey
City gynecologist Selig Leo Brauer,
MD, died on August 11, 1989. A
1905 Jersey City native, Dr. Brauer
kept a Jersey City private practice
for many years, retiring in 1985.
Dr. Brauer was graduated from the
University of Maryland Medical
School in 1929, and received his
New Jersey license the following
year. He was assistant attending at
Christ Hospital and Greenville
Hospital, both in Jersey City. A
member of our Hudson County
component and of the AMA, Dr.
Brauer received the Medical So-
ciety of New Jersey’s Golden Merit
Award in 1979 for 50 years of medi-
cal practice. During World War II,
Dr. Brauer was a major in the
United States Army.
Richard S. Colfax. At the age of
67, Richard Schoonmaker Colfax,
MD, died on October 11, 1989.
Born in Paterson in 1921, Dr. Col-
fax earned his medical degree at
New York Medical College in 1947;
he received his New Jersey license
in 1948. A resident and physician
in Pompton Lakes since 1949, Dr.
Colfax was affiliated with Paterson
General Hospital. In addition, Dr.
Colfax was the sports team physi-
cian for Pompton Lakes High
School. He was a member of our
Passaic County component and of
the American Medical Association.
Dr. Colfax served in the Army
Medical Corps attaining the rank
of lieutenant.
Mortimer I. Cowen. Retired
general practitioner, Mortimer I.
Cowen, MD, died on July 25, 1989.
Born in 1911 in Plainfield, Dr.
Cowen earned his medical degree
from the University of Zurich,
Switzerland, in 1936. After com-
pleting his internship at several
New York City hospitals, Dr.
Cowen entered the Civilian Con-
servation Corps program in 1940,
where he remained for one year,
serving as medical officer in Vir-
ginia. He was a first lieutenant in
the Medical Corps Reserve for the
United States Army from 1941
until the end of World War II, at-
taining the rank of lieutenant
colonel. He was awarded his New
Jersey license in 1946 and estab-
lished his general practice in Iselin.
During his career, he was affiliated
with Perth Amboy General Hospi-
tal and J.F.K. Medical Center,
Edison. Dr. Cowen was an emeri-
tus member of the Middlesex
County Medical Society and a
member of the American Medical
Association and of the Academy of
Medicine of New Jersey. In 1986,
Dr. Cowen received the Medical
Society of New Jersey’s Golden
Merit Award for 50 years of service
to the profession. Dr. Cowen re-
tired from active practice in 1983.
Joseph W. Fleisher. At the un-
timely age of 59, Joseph W.
Fleisher, MD, died on October 13,
1989. Born in Philadelphia, Dr.
Fleisher earned his medical degree
at Temple University Medical
School, Philadelphia, in 1955. He
served an internship at Albert
Einstein Medical Center, Philadel-
phia, and a residency in obstetrics-
gynecology at the same institution.
Dr. Fleisher received his New Jer-
sey license in 1961 and soon after
became a member of our Hudson
County component. For 28 years,
Dr. Fleisher was an obstetrician-
66
NEW JERSEY MEDICINE
gynecologist in Bayonne and
served as chief of obstetrics-
gynecology at Bayonne Hospital. A
diplomate of the American Board
of Obstetrics and Gynecology and
a fellow of the American College of
Obstetrics and Gynecology and of
the American College of Surgery,
Dr. Fleisher served as president of
his county medical society.
Henry C. Irving. A family phy-
sician in Jersey City for 50 years
before retirement, Henry Clay Irv-
ing, MD, died on September 23,
1989, at the age of 77. A lifelong
resident of Jersey City, Dr. Irving
received his medical degree from
Howard University College of
Medicine, Washington, DC, in
1937, and then was awarded his
New Jersey license. Affiliated with
two Jersey City hospitals, Jersey
City Medical Center and Green-
ville Hospital, Dr. Irving was a fel-
low of the American Academy of
Family Practice, and was a mem-
ber of our Hudson County compo-
nent and of the AMA. He received
the Golden Merit Award in 1987
from the Medical Society of New
Jersey. During World War II, Dr.
Irving served in the United States
Army medical corps as a captain.
Edward W. Jewell, III. A
member of our Bergen County
component, Edward William Jew-
ell, III, MD, died on October 18,
1989, at the age of 64. A
dermatologist, Dr. Jewell was a
past medical staff president of
Bergen Pines County Hospital,
Paramus, and also was affiliated
with The Valley Hospital, Ridge-
wood, and Chilton Memorial Hos-
pital, Pompton Plains. Born in
1924 in Iowa, Dr. Jewell received
his medical degree from St. Louis
University School of Medicine,
Iowa, in 1952, and was awarded his
New Jersey license in 1956. Dr.
Jewell was a diplomate of the
American Board of Dermatology
and a member of the American
Medical Association. He was a
Navy veteran of World War II.
Herbert Johnson. Obstetrician/
gynecologist Herbert Johnson,
MD, a member of our Camden
County component, died on
August 21, 1989, at the age of 80.
Born in 1908, Dr. Johnson received
his medical degree at the Univer-
sity of Pennsylvania Medical
School in 1936. He completed his
internship and residency at Cooper
Hospital, and was awarded his
New Jersey license in 1939. He
founded one of the first group
medical practices in southern New
Jersey, and served as chief of ob-
stetrics at Cooper Hospital from
1960 until his retirement in 1972.
In addition, Dr. Johnson was an
adjunct professor at Thomas Jef-
ferson University Hospital and at
the University of Pennsylvania.
After his retirement, he served as
the medical director of the Family
Planning Clinic of Gloucester
County. A member of the Ameri-
can Medical Association, Dr.
Johnson was a fellow of the Ameri-
can College of Surgeons, and a
diplomate of the American Board
of Obstetrics and Gynecology. Dur-
ing World War II, he served in the
South Pacific for the United States
Navy as a lieutenant commander.
Thomas D. Monte. Following 40
years of ophthalmology practice
and several years of retirement,
Thomas D. Monte of Montclair
died on September 23, 1989, at the
age of 77. A Brooklyn, New York,
native, Dr. Monte was awarded his
medical degree from Long Island
College of Medicine (now the
Medical College, State University
of New York) in 1936, and his New
Jersey license in 1939. Dr. Monte
served on the staff of St. Vincent’s
Hospital, Montclair, where he was
chief of ophthalmology and staff
president, and The Mountainside
Hospital, Glen Ridge. A diplomate
in ophthalmology and a fellow of
the American Board of Ophthal-
mology, Dr. Monte was a member
of the Pan-American Society of
Ophthalmology, of our Essex
County component, and of the
AMA. He received the Golden
Merit Award in 1986.
B. Ralph Wayman. A member
of our Mercer County component,
Bernard Ralph Wayman, MD,
died on October 17, 1989. Born in
1932 in Trenton, Dr. Wayman was
awarded his medical degree from
Jefferson Medical College, Penn-
sylvania, in 1963. He served an in-
ternship at Helene Fuld Hospital,
Trenton, and was awarded his New
Jersey license in 1964. Dr. Way-
man was the founder and director
of Glen Roc Medical Center, West
Trenton, and Morrisville Medical
Center, Pennsylvania. Dr. Way-
man was a member of the Ameri-
can Medical Association and
served as president of the Mercer
County Medical Society in 1978,
and also served his county as
treasurer, vice-president, and
chairman of various committees,
and he served his State Society as
a member of many councils. In
1978, Dr. Wayman was honored
with MSNJ’s Professional Service
Award. In addition to his medical
responsibilities, Dr. Wayman
wrote a column for the Trentonian
newspaper. From 1975 to 1983, Dr.
Wayman served as president of
Professional Data Corporation and
for the past six years, was presi-
dent of the Neighborhood Doctor
Center Corporation. Dr. Wayman
served in the United States Army
from 1953 to 1955. Other pro-
fessional responsibilities included
membership in the Speaker’s Bu-
reau of the American Medical As-
sociation, the National Board of
Medical Examiners, the American
Geriatric Society, the Royal So-
ciety of Health, the American
Heart Association, the Malprac-
tice Arbitration Board of New Jer-
sey, the Physician Service Review
Organization of Pennsylvania, and
the Academy of Medicine of New
Jersey. During his career, Dr. Way-
man was affiliated with Mercer
Medical Center, St. Francis Medi-
cal Center, and Helene Fuld Hos-
pital, all in Trenton.
VOL. 87— NUMBER 1 JANUARY 1990
67
EDITORIAL CRITERIA
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
vision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statement accompany-
ing material offered to NEW JER-
SEY MEDICINE must contain the
following language and must be
signed by all authors.
“In consideration of NEW JER-
SEY MEDICINE taking action in
reviewing and editing my sub-
mission, the author(s) undersigned
hereby transfers, assigns, or other-
wise conveys all copyright own-
ership to the Medical Society of
New Jersey, in the event that such
work is published in NEW JER-
SEY MEDICINE.
Specifications. Submit two
manuscripts that must be type-
written and double-spaced on 8V2"
by 11" paper. Statistical methods
should be identified.
Authors are asked to seek clar-
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tention to details of grammar,
spelling, and typing are important.
The title page should include the
full name, degrees, and affiliations
of all authors, and the name and
address of the author to whom re-
print requests and correspondence
should be sent.
The author should submit a 30-
word abstract.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission must be
submitted.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote
with the first use of the generic
name. Proprietary names of de-
vices should be indicated by the
registration symbol — ®.
References should not exceed 35
citations except in review articles,
and should be cited consecutively
by numbers in parentheses at the
end of the sentence. The reference
list should be typewritten and
double-spaced on separate 8V2" by
11" sheets in numerical order. The
style of NEW JERSEY MEDI-
CINE for references is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
viewers and the authors will be
permitted, but authors will be in-
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Reprint Orders. Reprints may be
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that order.
Communications. All com-
munications should be sent to the
editor, NEW JERSEY MEDI-
CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
68
NEW JERSEY MEDICINE
LOWER MEDICAL WASTE FEES
S-3867/A-5080 , introduced by Senator Dan Dalton ( D-Gloucester )
and Assemblyman Bob Shinn (R-Burlington) at the request of
MSNJ , passed the Legislature and was signed into law by
Governor Kean on January 2, 1990. The following maximum
charges now apply:
Under 50 lbs/yr $100
50-200 lbs/yr $300
Over 200-300 lbs/yr $500
Over 300-1,000 lbs/yr $1000
Over 1,000 lbs/yr $3500
The State Department of Environmental Protection has to refund
the difference between what it collected and what is due under
the new rate table. Refunds must be made by July 2, 1990.
MIIENJ DISTRIBUTES DIVIDEND
The Medical Inter-Insurance Exchange of New Jersey (MIIENJ) ,
which had declared an 11 percent dividend due on its 1978
policies, distributed the money in mid-January 1990. The
dividend was declared over two years ago but the Department of
Insurance refused to authorize release of the money. MIIENJ
legal counsel concluded the Department had no legal basis for
such a position so the MIIENJ Board of Governors proceeded
with the dividend payment.
MSNJ and MIIENJ SUE OVER MALPRACTICE SURCHARGE
The Medical Society of New Jersey (MSNJ) and the Medical
Inter-Insurance Exchange of New Jersey (MIIENJ) have begun
litigation against the Insurance Department over the proposed
malpractice surcharge. The Department wants to impose the
surcharge to recoup a $65 million loss caused by its
inattention to the mismanagement of the New Jersey Medical
Malpractice Reinsurance Association.
On January 19, 1990, Herbert Stern, MSNJ's special counsel,
filed a request with the Appellate Division to stay collection
efforts until the case is heard on an expedited basis.
Neither the New Jersey Hospital Association nor the Princeton
Insurance Company is opposed to the surcharge.
MEDICAL LICENSURE REFORM
S-2936 passed both Houses and was conditionally vetoed by the
governor. His conditions were acted upon by the Legislature
and the governor signed the bill into law. (continued)
NEWSWATCH
Page 2
Significant gains in the law for the physicians are:
1) Confidentiality in disciplinary proceedings except for
final adverse action.
2) Treating physicians of those undergoing rehabilitation
are exempt from reporting.
3) Physicians may not be sued for money damages for
failure to report.
4) Malpractice settlements cannot be introduced into
evidence before the State Board of Medical Examiners.
5) A review panel separate from the State Board of Medical
Examiners will investigate and review all but emergent
disciplinary cases.
6) Malpractice judgments may not form the basis of a
licensing action.
7) Separation of functions for deputy attorney generals
that advise the panel and the State Board of Medical
Examiners .
8) Burden of proof is elevated from the prior standard of
"to the satisfaction of the Board" to the legal standard
of "simple preponderance."
The governor refused to sign the bill with the standard sought
by MSNJ of "clear and convincing." Regardless of that event,
the legislation is a major advance in securing due process and
fundamental fairness for physicians.
SUPREME COURT TO HEAR PHYSICAL THERAPY SUIT
The Supreme Court has scheduled the suit by MSNJ against the
State Board of Physical Therapy for argument in mid-February.
MSNJ won a unanimous decision in the Appellate Division that
declared void, regulations that would permit therapists to
examine and treat patients without physician direction and to
modify physician prescriptions.
PRO LITIGATION ACCELERATES
The PRO suit against MSNJ has moved into active discovery.
MSNJ has secured 1,500 pages of PRO documents from the federal
government and the Court has authorized Society attorneys to
begin depositions.
PRO'S request for discovery and to take depositions has been
denied at this point and the legal counsel to the PRO has
withdrawn because of a potential "conflict."
MSNJ
NEWSLETTER
MEDICAID CLAIMS
PAYMENT BY
DIRECT DEPOSIT
A new convenience has been announced by Medicaid, electronic funds
transfer, that will become available in about a year. Physicians will have
the option of receiving claims payment automatically as a direct deposit
to the checking account. If you are interested in direct deposit of your
payments, please indicate in writing, to the following address: The State
of New Jersey, Department of Human Services, Division of Medical
Assistance and Health Services, CN 712, Trenton, NJ 08625, Attention:
EFT.
COLLECTION ADVICE
FROM I.C. SYSTEM, INC.
Unnecessary delay in going after bad debts can cost creditors more
money than ever before. In a recent decision by the U.S. Ninth Circuit
Court of Appeals, an Oregon collection agency was found to be in viola-
tion of the law by threatening adverse consequences if a debt was not
paid within ten days. “No fair,” said the court.
Debt collection agencies are required by the Fair Debt Collection Prac-
tices Act (FDCPA) to give people 30 days to dispute the validity of any
debt. The FDCPA applies to collections from individuals, rather than
businesses.
While not every debtor will become immediately aware of this new
opportunity to delay payments, it is one more reason for creditors to
move quickly when using a collection agency to assist them in recovering
difficult accounts.
MEDICARE When signing the Medicare attestation form, please note that you are
ESTATION stating that to your knowledge, the diagnoses and procedures shown in
the chart are accurate.
PROFESSIONAL Question: If a medical group, center, or hospital suspects an employed
pg§pQ|^§|QH'|yY physician of having an alcohol problem or has discovered that the phy-
sician employee has had an arrest due to such a problem, are the em-
ployers in any way liable for not addressing the issue with the employee
if a suit should ever be filed against that employee? Answer: The courts
hold hospitals and physician-employers responsible for ascertaining the
fitness of physicians in their employ to render appropriate care to the
patients entrusted to their care. If there is valid evidence to indicate
the presence of an alcohol problem, the employer does indeed have a
responsibility to take appropriate action to identify and correct that
problem. If the physician presents a risk to patients, the physician
should be removed from patient contact until the illness is under
documented, effective control. In some instances, especially if formal
hospital staff action is taken, there may be a requirement to notify the
State Board of Medical Examiners. In all such cases, the Medical Society
of New Jersey’s Physicians’ Health Program is available to provide
advice and assistance.
CHILDREN’S Have you ever questioned the value we place on children in our society?
TRUST FUND Almost every walk of life requires training, be it computers or carpentry.
VOL. 87— NUMBER 2 FEBRUARY 1990
79
MSNJ NEWSLETTER
Yet you can go all the way through high school and college and never
receive a single hour of instruction in how to be a parent. It seems we
expect people to be able to raise children on instinct. Parenting is
stressful. Sometimes that stress results in children hurt and lives shat-
tered. In the past few years, we have been made uncomfortably aware
of the problem and prevalence of child abuse and neglect and its devas-
tating effect on our society. Last year nearly 57,000 reports of child abuse
and neglect were recorded in New Jersey. Many of these children grow
up to be abusive parents.
The time to stop child abuse is before it starts, and you can help. You
can donate to the Children’s Trust Fund. The Fund was created by law
in 1985 to encourage and finance community-based child abuse preven-
tion programs throughout the state. In 1989, the Fund awarded $530,071
to 28 community organizations which offer a variety of services to chil-
dren and parents including parenting education classes, self-help groups,
respite care, behavior management, counseling, therapy, and communi-
ty education efforts. Public donations and the federal challenge grant
are the primary source of money for the Fund. A check-off system on
state income tax returns is an easy way to designate a portion of your
refund directly to the Fund. In addition to the check-off, you can send
a donation at any time to the Children’s Trust Fund To Prevent Child
Abuse, CN 711, Trenton, NJ 08625.
HALFWAY HOUSE In an effort to break the addictive patterns of mentally ill chemical
PROGRAM abusers (MICAs), Greystone Park State Psychiatric Hospital has opened
20 cottages as halfway houses for recovering patients. A spokesperson
for Greystone stated that the cottage program will resemble traditional
28-day alcohol inpatient rehabilitation treatment programs, but the av-
erage stay will be between 60 to 90 days. The program will involve
emphasis on one-on-one counseling and group therapy, and will focus
on intervening in addictive thought patterns and in raising patients’ self-
esteem. Patients will be admitted to the cottage program after they have
completed detoxification, and will be closely monitored.
Public Advocate Alfred Slocum plans to file actuarial information with
the State Insurance Department that will challenge rate increases being
sought by Blue Cross and Blue Shield of New Jersey. The rate hikes
would increase rates paid by 350,000 individual policyholders by 33.7
percent, and increase the rates paid by 255,000 senior citizens for
Medigap coverage by 28.9 percent a year. The rate increases being sought
would increase Medigap premiums by $124, family coverage by $2,400
a year, and single coverage by about $440 per year. If the insurance
commissioner does not act, the rate increases will go into effect automati-
cally on February 1, 1990. Slocum has not stated what he feels the rate
increases should be, but has said that it should not be what the Blue’s
are seeking. Blue Cross and Blue Shield are seeking the increases to trim
the corporation’s $230 million deficit.
SEVERITY OF Severity of Illness (SOI) data will not be incorporated into the 1990 rates.
DATA However, a new project will study two different SOI systems during 1990.
All Chapter 83 hospitals will be involved in the study and have their
costs of participating in the study reimbursed through their markup
factors. The data to be collected will be based on 1988 discharges instead
of current year discharges.
UNCOMPENSATED The Health Care Administration Board approved the revised regulations
CARE related to complying with the uncompensated care legislation. These
PUBLIC ADVOCATE
CHALLENGES
RATE INCREASES
80
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
regulations are scheduled to be published in the December 18, 1989, New
Jersey Register. The Department indicated that the costs of complying
with the regulations could be appealed as a legal change. In an effort
to avoid processing individual hospital appeals, the Department antici-
pates creating a generic appeal methodology. The Department has not
finalized the audit procedures related to uncompensated care but is in
the process of developing the guidelines.
HOSPITAL The Department indicated that the 1990 rate packages were being
RATE PACKAGES mailed to hospitals and that current simulations do not imply the need
for protective corridors to soften the impact of rebasing in 1990.
HOSPITAL Hospitals are required to use New York’s Version 7 DRGs. The Depart-
REGULATIONS merd a^so anticipates incorporating Medicare cost shifts on a prospective
basis in 1990.
LOANS FOR The Department is working with the New Jersey Health Care Facilities
WORKING CAPITAL Financing Authority to get legislation passed that would permit the
Authority to offer loans for working capital. Working capital loans may
possibly be used to stabilize markup factors throughout the year. The
Department indicated its intentions to include reasonable working capi-
tal interest payments in hospitals’ reimbursable costs.
HEALTH CARE According to the research firm A. Foster Higgins, employer health care
QQgyg INCREASE costs increased 16.5 percent in 1989. The study concluded that “managed
care’’ health care plans failed to provide “cost-efficient services.”
FRAUD AND Health and Human Services (HHS) Office of the Inspector General
ABUSE REGULATIONS (OIG ) has drafted final rules amending the 1977 Medicare fraud and
abuse law. The final fraud and abuse regulations that are awaiting HHS
Secretary Louis Sullivan’s approval contain dozens of provisions govern-
ing business arrangements that affect provider/patient relationships.
Under the draft rules, hospitals would be allowed to waive Medicare
beneficiary inpatient copayments and deductibles. Hospitals may not
discriminate among inpatients in the waiving of copayments and deduc-
tibles on the basis of length of stay or type of disease. Hospitals that
do discriminate or are found to claim the waived amounts as Medicare
bad debts would be subject to civil or criminal enforcement actions by
the OIG.
According to the OIG, copayment and deductible waivers are restricted
to inpatient services since it is deemed not to affect the demand for such
services. Nursing homes, home health agencies, and other cost based
providers are barred from waiving of patient copayments and deduc-
tibles.
The rules, to be published this year, also include provisions dealing with
joint ventures, lease arrangements, purchases of physician practices, and
physician recruitment activities.
According to a survey conducted by the Group Health Association of
America (GHAA), the inpatient utilization rates in 1987 for HMO en-
rollees was significantly lower than the national average. According to
the GHAA survey, HMO enrollees under age 65 used an average of 352
days of inpatient services per 1,000 enrollees versus a national average
of 588 days. For those 65 and over, the HMO utilization was 1,690 days
per 1,000 enrollees versus a national average of 3,030 days. HMO en-
rollees had an average length of stay of 4.7 days versus a national average
of approximately 7.1; however, HMO enrollees on average had 4.8 phy-
HMO
UTILIZATION
VOL. 87— NUMBER 2 FEBRUARY 1990
81
MSNJ NEWSLETTER
sician visits per year versus a national average of 4.3. The GHAA at-
tributes the utilization difference to HMO practice styles and population
variances. The GHAA survey encompassed 259 HMOs with a total en-
rollment of approximately 20 million members.
MEDIGAP A General Accounting Office (GAO) study reports the ultimate repeal
PREMIUMS the Medicare catastrophic coverage legislation would increase
Medigap policy premiums. According to House Ways and Means Health
Subcommittee Chairman Fortney A. (Pete) Stark, who released the
study fact sheet, the repeal will be costly for the 24 million elderly
Medigap policy holders. The study concludes that the cost of Medigap
coverage will be more than the calendar year 1990 catastrophic
premiums.
SEQUESTRATION Carriers have been instructed by HCFA on the implementation of se-
BNSTRUCTIONS questration reduction in Part B payments mandated by the sequestra-
tion order signed into law on October 15, 1989, under the Gramm-
Rudman-Hollings Act. The carriers were instructed to withhold 2.092
percent of all Part B payments for services and equipment. The increased
withholding amount was necessary to achieve the 2 percent reduction
for fiscal year 1990. The reduction is effective for services on or after
October 17, 1989. The calculation of the portion of the charge subject
to the Part B deductible is not affected by the payment reduction, but
the charge on which the 20 percent coinsurance is based is subject to
reduction.
PHYSICIAN
PAYMENT
REFORM
Health and Human Services has issued a lengthy report to Congress on
issues related to physician payment reform. The report focuses on issues
regarding the use of a relative value scale for physician reimbursement,
the implementation of a national fee schedule, and increases in the
volume/intensity of physician services. In the report, HHS discusses
reservations about the proposed resource-based relative value scale
(RBRVS) used in current reform proposals and recommends additional
controls to reduce the expected growth in the volume and intensity not
controlled by the RBRVS alone. In the report, HHS also indicated a
preference for a lengthy phase-in of a national fee schedule, if enacted,
after an advance notice of two years.
HMOs DROP According to HCFA, only four HMOs will drop out of Medicare in 1990,
FROM MEDICARE marking the smallest decline in HMO Medicare participation since the
program began in 1985. The four HMOs have a total Medicare enroll-
ment of about 11,000. In 1989, 32 HMOs covering 62,000 Medicare
beneficiaries withdrew from the program. While acknowledging that
HMO participation in Medicare is stabilizing, the Group Health As-
sociation of America called the HCFA information misleading. Accord-
ing to the GHAA another six HMOs covering more than 57,000
beneficiaries will convert to less comprehensive contracts in 1990. There
are 196 HMOs participating in the Medicare program with an estimated
enrollment of 1.82 million Medicare beneficiaries.
SOCCER There are physicians who play soccer for fun and exercise. If you have
ANYONE? a team that would like to play in the first U.S.A. Medical Tournament
to be held in Houston in April 1990, contact the Houston Soccer Medical
Association, 6565 DeMoss, Suite 230, Houston, TX 77074. In addition,
there will be CME activities, a fashion show, and dinner dance.
FINI “When you betray somebody else, you also betray yourself.”
82
NEW JERSEY MEDICINE
PROFESSIONAL
LIABILITY
COMMUNICATING A bad result during the course of medical care or treatment is distressing
AFTER A MEDICAL to both physician and patient. It can be difficult for a patient to under-
COM PLICATION s^an<^ that a had result does not necessarily imply negligence. A clinician
attending a patient who has a less than favorable outcome needs to be
particularly careful to maintain the rapport he has established with the
patient during the course of treatment. If the physician is able to respond
sympathetically and nondefensively to the patient’s concerns, he will
diffuse much of the anger and confusion that often provoke the decision
to bring a medical malpractice suit.
The following case summary is illustrative of two approaches to an
unfortunate result and the impact each approach had on the patient’s
decision to bring suit:
CASE REPORT Mrs. Patient, a 26-year-old gravida II para 0 with no significant prenatal
problems, was admitted to labor and delivery at the end of her 39th week
of pregnancy. Dr. Defendant, on call for the patient’s obstetrician, had
not seen the patient before, and Nurse Care, a hospital staff nurse,
attended Mrs. Patient. Her labor progressed slowly and without difficul-
ty, and Dr. Defendant told Nurse Care he would return to his office,
close to the hospital, to attend to office patients and asked that she keep
him advised of the patient’s progress.
A telephone call was received by Dr. Defendant’s office two hours later.
Nurse Care told Dr. Defendant that Mrs. Patient was completely dilated
and pushing. There were type III decelerations with pushing and the
patient was turned on her side and given oxygen. Nurse Care explained
that during several contractions prior to the telephone call, she noted
the onset of a drop in the fetal heart rate to 100 and then lower to 80.
The vertex was at approximately plus 2 station. Nurse Care asked the
doctor to come to the hospital to evaluate the patient and Dr. Defendant
advised Nurse Care that she should prepare the patient for immediate
forceps delivery and transport her to the delivery room.
Dr. Defendant’s examination in the delivery room revealed the vertex
to be plus 1 to plus 2 station, with the patient completely dilated.
Amniotic fluid was clear and the fetal heart rate was 65 to 70 beats per
minute. The patient was prepped and draped and a rapid midforceps
delivery was accomplished without difficulty.
The baby was born with no palpable heart rate, no spontaneous respi-
rations, virtually no muscle tone, no reflex irritation, but some skin color.
Apgar score at one minute was 1. The infant was immediately placed
on the Air Shield Radiant Warmer and external cardiac massage was
instituted. The infant was bagged via mask with 100 percent oxygen.
Spontaneous heart rate of greater than 100 beats per minute resumed
within 15 seconds of application of external cardiac massage and the
infant pinked up. At the time of resuscitation, Dr. Right, the pedia-
trician, was summoned and he arrived immediately, assuming responsi-
bility for further resuscitation.
VOL. 87— NUMBER 2 FEBRUARY 1990
85
PROFESSIONAL LIABILITY
The Apgar score at five minutes was 4. At 10 minutes, Apgar score was
5, and spontaneous sustained respirations had been established. The
infant was transferred to another hospital’s intensive care unit nursery.
The baby was found to have brain damage, resulting from proved hypox-
ia for 20 to 30 minutes prior to delivery. Presently, the child has cerebral
palsy with spastic quadriplegia and athetosis. He requires extensive
medical and rehabilitative care. Mr. and Mrs. Patient were devastated
by the child’s problems. Because Mrs. Patient had gone through a
normal pregnancy she believed that either Dr. Defendant or Dr. Right
was at fault and had caused her child’s condition.
FOLLOWUP CARE Soon after the delivery, Dr. Right, the pediatrician, met with Mr. and
Mrs. Patient at length. He explained what had happened during labor
and delivery, the problems the family could expect, and how he could
help them from that point on. He finished the conversation by saying
he was very sorry their baby had suffered complications, and that he
would be pleased to provide any further services.
Dr. Defendant, who was aware the pediatrician had met with the
parents, did not contact them after the delivery of their infant. He
believed it was sufficient that the pediatrician had spoken with the
parents. Three weeks later, he learned Mr. and Mrs. Patient wished to
meet with him and he did so immediately. However, that meeting was
evidently not satisfactory to the parents. Mrs. Patient brought suit
against Dr. Defendant, but not against Dr. Right, stating she did not
believe Dr. Right had been negligent because he had been so forthcoming
and helpful immediately after the delivery. She felt Dr. Defendant had
abandoned her after the delivery and that perhaps he had something
to hide.
Although the jury ultimately rendered a defense verdict at trial, the case
dragged on for five years and cost $300,000 to defend. While Dr. Defen-
dant had not been negligent in his management of the case, he had failed
to communicate effectively with Mrs. Patient and her family following
the delivery.
INFORMED CONSENT As previously noted, while unfortunate outcomes are a difficult part of
professional practice, they do not necessarily warrant blame or litigation.
While an explanation of a bad outcome may not always prevent blame
or a lawsuit, a frank discussion of the problem within a reasonable time
often helps to assuage the patient’s feelings of anger and distrust. “Pa-
tients sometimes retain legal counsel specifically to investigate the cause
of a problem or unsuccessful treatment, especially if they are distrustful
because they did not have a timely and satisfactory discussion with the
approximate health care professional,” according to Dan J. Ten-
nenhouse, MD, JR, FCLM (Risk Prevention Skills, 1988).
The informed consent process can help set the tone and prepare the
patient for a difficult discussion after a disappointing result. When the
physician provides the patient with the information necessary for in-
formed consent, he not only is empowering that patient to make an
educated decision, he also is preparing the patient for coping with pos-
sible complications and inviting the patient to be a part of the health
care team. In doing so effectively, the physician can build a good doctor/
patient relationship, that is invaluable if a problem or bad result occurs.
Just as a physician prepares the patient for the possibility of a bad
outcome, the physician should prepare for his own reactions should the
situation occur. It is helpful to plan what to do in the case of such an
86
NEW JERSEY MEDICINE
PROFESSIONAL UABIUTY
event before it happens, so that the physician can continue to provide
effective treatment and keep good rapport with the patient.
Is an apology a good idea? An explanation is better. Many doctors are
afraid to discuss a bad outcome, or even a tragedy, because an apology
as such denotes blame or negligence. However, an expression of sorrow
and sympathy implies neither personal responsibility nor negligence. A
simple, “I am so sorry this happened,” is a far cry from “I’m sorry, it
was all my fault that you have these problems. It never should have
happened.” When a friend sustains a loss, such as a death in the family,
it is customary to tell the person that you are sorry the loss occurred.
It does not imply that you were at fault, but that you empathize with
the unhappy time that the friend is experiencing. A sincere demon-
stration of empathy from a physician lets the patient know the doctor
cares and is not unmoved by the outcome. When the clinician shares
his feelings of sadness and frustration with all concerned, the patient
and family are reminded that their doctor is indeed human, just like
them.
SUMMARY When a less than optimal outcome occurs, a plan of action is very
important. It can be summarized in a few sentences: Recognize the
patient’s frustration and fear. Recognize your own feelings of disappoint-
ment and anxiety. Don’t panic; keep lines of communication open.
Express sorrow that the bad result occurred, but avoid faultfinding or
fingerpointing. Explain the situation and your proposed plan of action
in terms that the patient can understand. Keep the patient and family
informed and involved in the subsequent treatment plans and decisions.
(Reprinted with permission from Claims RX, NORCAL Mutual In-
surance Co., San Francisco, CA, September 1989.)
NOT LIABLE FOR A physician who asked another physician to cover for him was not liable
COVERING PHYSICIAN for the covering physician’s alleged malpractice, an Arizona appellate
court ruled. After a patient had a dilation and curettage (D&C), the
physician prescribed drugs to control pain and bleeding. The patient
continued to suffer pain, bleeding, and fever, and called the physician
twice after the operation. When she called a third time, the physician’s
answering service had the covering physician answer the call. The cover-
ing physician refilled the patient’s prescriptions. The patient had an
infection as a result of the D&C. About six days after she spoke to the
covering physician, she was admitted to a hospital, where her entire
reproductive system was removed.
The patient sued her original physician. The trial court instructed the
jury that the referring physician was not liable for the negligence of the
covering physician as long as he exercised reasonable care in selecting
the covering physician. The court rendered a verdict for the physician.
On appeal, the court said that a physician was not liable for a
substitute’s negligence unless the substitute physician was in his em-
ployment or was his agent or partner or unless due care was not used
in making the substitution. In the present case, there was no evidence
that the covering physician was in the physician’s employ or was his
agent or partner and there was no evidence the physician was negligent
in selecting the covering physician.
Since there was no legal or actual authority or control of the covering
physician by the regular physician, the court found that no agency had
been proved and affirmed the lower court’s judgment. (Reprinted with
permission from The Citation, AMA, Volume 59, October 1, 1989.)
VOL. 87— NUMBER 2 FEBRUARY 1990
87
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LEVOXINE® (Levothyroxine Sodium Tablets, USP) For oral administration
The following is a brief summary. Before prescribing, please consult package insert
INDICATIONS AND USAGE:
LEVOXINE (L-thyroxine) tablets are indicated as replacement or supplemental therapy
for diminished or absent thyroid function, resulting from functional deficiency, primary
atrophy, from partial or complete absence of the gland or from the effects of surgery,
radiation or antithyroid agents. Therapy must be maintained continuously to control the
symptoms of hypothyroidism.
CONTRAI N DICATIONS:
L-thyroxine therapy is contraindicated in thyrotoxicosis, acute myocardial infarction
and uncorrected adrenal insufficiency.
WARNINGS:
Drugs with thyroid hormone activity, alone or together with other therapeutic agents, have
been used for the treatment of obesity. In euthyroid patients, doses within the range of daily
hormonal requirements are ineffective for weight reductioa Larger doses may produce
serious or even life-threatening manifestations of toxicity, particularly when given in as-
sociation with sympathomimetic amines such as those used for anorectic effects
PRECAUTIONS:
Caution must be exercised in the administration of this drug to patients with cardiovas-
cular disease. Development of chest pains or other aggravation of the cardiovascular dis-
ease requires a reduction of dosage
Patients on thyroid preparations and parents of children on thyroid therapy should be
informed that replacement therapy is to be taken essentially for life They should im-
mediately report during the course of therapy any signs or symptoms of thyroid hormone
toxicity, eg, chest pains, increased pulse rate, palpitations, excessive sweating, heat
intolerance, nervousness or any other unusual event In case of concomitant diabetes
mellitus the daily dosage of antidiabetic medication may need readjustment In case of
concomitant oral anticoagulant therapy, the prothrombin time should be measured fre-
quently to determine if the dosage of oral anticoagulants is to be readjusted.
Partial loss of hair may be experienced by children in the first few months of thyroid
therapy, but this is usually a transient phenomenon and later recovery is usually the
rule.
Drug Interactions — In patients with diabetes mellitus addition of thyroid hormone
therapy may cause an increase in the required dosage of insulin or oral hypoglycemic
agents
Patients stabilized on oral anticoagulants who are found to require thyroid replace-
ment therapy should be watched very closely when therapy is started.
Cholestyramine binds both T4 and T3 in the intestine, thus impairing absorption of
these thyroid hormones Four to five hours should elapse between administration of
cholestyramine and thyroid hormones
Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients without a
functioning thyroid gland who are on thyroid replacement therapy may need to increase
their thyroid dose if estrogens or estrogen-containing oral contraceptives are gives
Drug/Laboratory Test Interactions — The following drugs or moieties are known to inter-
fere with laboratory tests performed on patients taking thyroid hormone: androgens cor-
ticosteroids estrogens oral contraceptives containing estrogens iodine-containing
preparations and the numerous preparations containing salicylates
Carcinogenesis, Mutagenesis, And Impairment of Fertility — A reported apparent as-
sociation between prolonged thyroid therapy and breast cancer has not been confirmed
No confirmatory long-term studies in animals have been performed to evaluate car-
cinogenic potential, mutagenicity, or impairment of fertility in either males or females
Pregnancy-Category A — The clinical experience to date does not indicate any adverse
effect on fetuses when thyroid hormones are administered to pregnant women.
Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human milk
Thyroid is not associated with serious adverse reactions and does not have a known
tumorigenic potential. However, caution should be exercised when thyroid is adminis-
tered to a nursing woman
Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Routine
determinations of serum (T4) and/or TSH is strongly advised in neonates in view of the
deleterious effects of thyroid deficiency on growth and developmenl
ADVERSE REACTIONS:
Adverse reactions are due to overdosage and are those of induced hyperthyroidism.
OVERDOSAGE — Excessive dosage of thyroid medication may result in symptoms of
hyperthyroidism, which may not appear for one to three weeks after the dosage regimen
is begun The most common signs and symptoms of overdosage are weight loss, palpita-
tion, nervousness, diarrhea or abdominal cramps, sweating, tachycardia, cardiac arrhy-
thmias angina pectoris tremors headachs insomnia, intolerance to heat and fever. If
symptoms of overdosage appear, discontinue medication for several days and reinstitute
treatment at a lower dosage leveL
Complications as a result of the induced hypermetabolic state may include cardiac
failure and death due to arrhythmia or failure
Dosage should be reduced or therapy temporarily discontinued if signs and symptoms
of overdosage appear.
Treatment of acute massive thyroid hormone overdosage is aimed at reducing gas-
trointestinal absorption of the drugs and counteracting central and peripheral effects,
mainly those of increased sympathetic activity. Measures to control fever, hypoglycemia, or
fluid loss should be instituted if needed.
DOSAGE FORMS AVAILABLE:
LEVOXINE (L-thyroxine) tablets are supplied as oval, color coded, potency marked
tablets in 11 strengths: 12Vi meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - orange,
50 meg (0.05 mg) - white, 75 meg (0.075 mg) - purple 100 meg (0.1 mg) -yellow, 112 meg
(0.112 mg) - rose 125 meg (0.125 mg) - browe 150 meg (0.15 mg) - blue, 175 meg
(0.175 mg) -turquoise, 200 mcg(0.2 mg)- pink and 300 meg (0.3 mg)- greee in bottles of
100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg and
500 meg injectable (see injectable package insert).
88
NEW JERSEY MEDICINE
PRESIDENT’S
PAGE
STRATEGIC One of the most important goals for your Board of Trustees has been
PLANNING revitalize and organize our process of long-range or strategic planning.
In my speech to the House of Delegates last spring, I stated: “Strategic
planning is a most important challenge. . . . We must look carefully and
critically at ourselves, to see where we have been and where we should
be going, and to prepare ourselves to anticipate and meet the challenges
and opportunities of the future.”
At the same time, I also stated: “I have directed our Long-Range Plan-
ning Committee to promptly begin a thorough and wide-ranging process
of evaluation and planning.” They have been working toward that goal
for many months now.
What is long-range planning? It may be easier, at first, to state what
it is not. It is not an attempt to predict the future; this at best, would
be a fruitless task. Neither is it an attempt to make future decisions
now, nor an attempt to simply program change.
Strategic planning (a better term than long-range planning) is a process
of making decisions for today, that may affect us tomorrow. It is a process
of providing continuity and consistency, or recognizing patterns, as well
as a process of programming change. It is a process of dealing with
today’s problems today, so that we will be ready to deal with tomorrow’s
problems. Although we cannot make tomorrow’s decisions, we must
make decisions that will maintain our options.
An organization must consider what it may wish to do tomorrow, and
how to maintain that option today. An organization must recognize
needs and potential needs, and must plan the use of finite resources to
attain those goals. An organization must set priorities and develop a
strategic plan of action. Indeed, a strategic plan may be considered to
be a set of priorities, for that year. By reviewing this annually, a dynamic
process is created, determining whether new priorities have emerged.
Strategic planning is necessary if we are to understand our alternatives
and maintain our options. The process is necessary if we are to substitute
careful planning for reactive tactics. It is necessary if we are to minimize
those crisis situations requiring crisis measures. It is a process of iden-
tifying our most important goals, committing our resources to these
goals, and then monitoring and evaluating the result.
This process must be organized. It cannot “just happen.” Our Board
members are devoted to current agenda items. These sessions cannot
reasonably deal with the strategic planning process within the time
constraints of that monthly meeting, and within the context of an open
structured meeting.
Furthermore, planning should not be limited to members of the Board
of Trustees. An organization that limits strategic planning to a small
group in the hierarchy is doomed to an elitist policy. With this in mind,
our Committee on Long-Range Planning was restructured completely
VOL. 87— NUMBER 2 FEBRUARY 1990
91
PRESIDENT’S PAGE
this year (the only Medical Society council or committee to undergo such
a sweeping change). A chairman was selected who never has been a
member of our Board of Trustees, but who has had significant experience
with the strategic planning process. One current member of the Board
of Trustees was selected and assigned to this Committee. One past-
president of the Medical Society of New Jersey was selected and assigned
to this Committee. One former member of the Committee on Long-
Range Planning was reappointed. Other members of this Committee
were selected for their representation of segments of our Society. This
Committee on Long-Range Planning has been at work over past months,
with the specific charge of developing the foundation for our plan, for
presentation to the Board of Trustees.
That presentation is scheduled to take place in the near future, at a two-
day long-range planning retreat, a time for the Board to temporarily set
aside its concerns with our day-to-day problems, and look at the broader
picture and the longer horizon. The Committee on Long-Range Planning
will meet with the Board of Trustees at this session, and our session will
be coordinated by a neutral “outside” facilitator. The Board will con-
sider, and have the opportunity to alter or amend the plan; it will
consider whether any change in our organizational structure is necessary
to accomplish these goals; it will identify the responses needed to meet
the goals.
It is our intent that the plan developed will be a workable plan. Indeed,
an important part of the function of the retreat will be to develop a
program to implement the strategy; and this may be even more difficult
than developing the plan itself.
Finally, if the process is to be effective, it must be ongoing. We must
continue to evaluate and re-evaluate our goals, our strategies, our suc-
cesses, and our failures. We must continue to work formally with this
process, and to update it at regular intervals. Only in this way will the
Medical Society of New Jersey be most effective on behalf of all of its
membership.
LETTERS TO THE The President of MSNJ welcomes letters from the physician community.
PRESIDENT Please address your comments to Dr. Paul J. Hirsch, Medical Society
of New Jersey, Two Princess Road, Lawrenceville, NJ 08648. □
92
NEW JERSEY MEDICINE
EDITOR’S
DESK
CAESAR’S Can anyone be above suspicion when a charge of conflict of interest
WIFE arises?
Can anyone be trusted without signing an affidavit of trustworthiness?
As we noted in the November 1989 issue of NEW JERSEY MEDICINE,
all publications should attempt to insure the accuracy of their published
materials. However, there is disagreement in the “how” as well as the
“how far” authors could and should be pushed in the interests of ac-
curacy.
The editors of three of the most prestigious United States journals, New
England Journal of Medicine, Annals of Internal Medicine, and Journal
of the American Medical Association (JAMA), along with others, con-
tinue to wrestle with measures to better assure their readerships the
validity of articles in their publications.
In trying to reduce misrepresentations and fraud, Arnold S. Reiman,
MD, of New England Journal of Medicine expects prospective authors
to disclose any “commercial interests” that might produce conflict of
interest. He also intends to have them attest, in writing, to the integrity
of their work.
The Annals of Internal Medicine and its editor, Edward J. Huth, MD,
require an agreement be signed before publication can be considered.
This is to affirm the exclusivity of the manuscript to the Annals, that
those listed as authors were truly such and will assume responsibility
for the work, that any prior publication of the material, even in part,
is disclosed, and that all necessary informed consents have been ob-
tained.
George D. Lundberg, MD, of JAMA, goes further. He will have authors
certify not only that they will divulge possible conflicts of interest and
that they are responsible for the reliability of the work, but also, most
uniquely, that they will surrender their raw data upon request.
Dr. Lundberg’s proposal has been criticized as being too naive — the true
rascal can manufacture false data just as easily as he can falsify the final
manuscript. The signature written by such a scoundrel is worth nothing,
and scrutinizing faked data undoubtedly will lead the editorial staff to
erroneous conclusions.
There are other risks associated with the “Lundberg Policy.” Like it or
not, intended or not, JAMA now will become the guarantor of its pub-
lished materials, regardless of the extent of presubmission review by
sponsoring institutions. Should an article(s) later prove to be false or,
much worse, fraudulent, JAMA will bear responsibility and guilt equal
to that of the authors. Additionally, it may become necessary for JAMA
to have a statistician review every manuscript, not just selected ones,
thus greatly increasing the cost of review and delaying the timeliness
of publication.
VOL. 87— NUMBER 2 FEBRUARY 1990
95
EDITOR’S DESK
The “Lundberg Policy” also carries negative connotations. It reminds
us of other efforts at attestation, past and present, that have raised the
hackles of much of society, including the physician community. Today’s
demeaning, and probably worthless, mandate for attestation in Medicare
cases is reminiscent of other worthless affidavits, e.g. honor code pledges
and anticommunist loyalty oaths. None is worth the paper on which the
ink resides. The honorable person is affronted; the dishonorable one
couldn’t care less. What do we mean by trust?
Nevertheless, we should continue our efforts to prevent false reporting
and fraud. We have little quarrel with attempts to insure disclosure of
potential commercial conflicts of interest. Dr. Lundberg’s proposal is
noble, but misguided, to coin a phrase. It is impetuous and premature.
We feel that publications should join forces in a collaborative effort,
rather than flying solo. It is time to reach consensus on what is best for
author and reader. We suggest a conference whose participants include
editors of both large and small publications, members of prominent
think tanks, educators, and (necessarily, albeit reluctantly) representa-
tive(s) of the governmental agencies that fund much of the research.
Dr. Lundberg should not have to fear that JAMA may not be able to
“compete” with other journals for manuscripts because of his stringent
new guidelines. Nor, conversely, should other journals risk denigration
because they do not, at least superficially, “guarantee” the same quality
of review as JAMA ; and this worry is not a good reason for others to
adopt the rash and precipitous “Lundberg Policy.” Individuality is fine
and some variation is to be expected, but there should be agreement
on basic standards for medical and scientific publications.
JOURNAL With the tremendous increase in research being performed in New Jer-
ARTIOLES sey, the Committee on Publication voted to increase the documentation
on research published in NEW JERSEY MEDICINE. As of the January
1990 issue of our journal, all articles include the date the article was
received and the date of acceptance by NEW JERSEY MEDICINE. The
Committee believes this policy will give authors more appropriate credit
for their original research and provide for timeliness of reporting of the
work being done in New Jersey. □
96
NEW JERSEY MEDICINE
BOOK
REVIEWS
OTOLARYNGIC ALLERGY
AND IMMUNOLOGY
Helen F. Krause, MD. Philadelphia, PA, W.B. Saunders Co., 1989. The
text provides a superficial overview of the immune system as it relates
to the practicing otolaryngologist. A redeeming nature to the book is the
color photographs, detailed photomicrographs, x-rays, and detailed pic-
tures. However, the authors of the various chapters basically are from
the clinical setting, i.e. private practitioners with clinical appointments.
The scientific basis to several of the discussed techniques is superficial
and sometimes elementary (figure 21-1, page 156). A major strong point
of this text is that it offers the surgically oriented alternative to allergic
disorders. In general, there are several other good “allergy texts” that
provide a more indepth reading and understanding in the various areas.
However, for a general practitioner not wishing to pursue such an in-
depth analysis, this text would provide an easy introduction into the
area. □ Leonard Bielory, MD
PEDIATRIC
EXERCISE
SCIENCE
Thomas J. Rowland, MD (ed). Champaign, IL, Human Kinetics Pub-
lishers, Inc., 1989. This is the initial issue of what apparently is a new
journal of the North American Society of Pediatric Medicine. The stated
purpose of the journal is to increase the understanding of exercise in
children and adolescents, i.e. how participation in sports affects the
mental and physiological growth in both healthy and chronically ill or
handicapped children. The first issue contains excerpts and review
articles from relevant literature as well as four research articles on topics
such as children’s gait, relative endurance, characteristics of female
swimmers, and a pure basic science paper. The journal is intended for
pediatricians and basic physical educators in the fields of biomechanics
and exercise physiology. The articles are well edited and readable. For
those interested in the field of sports medicine, this appears to be a useful
journal. □ Christine E. Haycock, MD
PRIMER OF
DERMATOPATHOLOGY
AF Hood, MD, TH Kwan, MD, DC Burnes, MD, MC Mihm, Jr, MD.
Boston, MA, Little, Brown & Co., 1984. This softcover, glossy paged book
is precisely what its title proclaims. It presents a systematic approach
to the differential diagnosis of microscopic sections of most skin diseases.
The reader is instructed how to examine the material on the slide and
how to recognize and categorize patterns of abnormality. The book then
is arranged in chapters and sections which correspond to such major
morphologic characteristics, e.g. epidermis — vesicles and bullae, hyper-
plasias, atrophies, dermis — perivascular infiltrates, upper or reticular
dermis, diffuse infiltrates. Each condition or disease is described as a
list of diagnostic features rather than a narrative text. Accompanying
black-and-white photomicrographs, and very useful line drawings dem-
onstrate representative findings. There are very few comments related
to the clinical condition, rather, the reader is provided a list of selected
references at the end of each chapter. The book will be a helpful lamp
for those taking their first unsure steps into the mysterious terrain of
dermatopathology. □ Christopher M. Papa, MD
VOL. 87— NUMBER 2 FEBRUARY 1990
99
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100
NEW JERSEY MEDICINE
Z LETTERS &
VIEWPOINTS
CESAREAN The following letters concern the problem of the increasing rate of
SECTION cesarean sections in New Jersey. The first letter is from a New Jersey
RATES obstetrician, and the response to his letter was written by Commissioner
of Health Molly Joel Coye.
REDUCING THE I am writing in response to Dr. Coye’s letter of October 1989, addressed
C-SECTION RATE to “All Hospital CEOs,” concerning cesarean section rates in the state
of New Jersey. I am a practicing obstetrician in the state of New Jersey
and have a very active practice.
My colleagues and myself are forced to choose between two possible
explanations for Dr. Coye’s recent actions, either she does not truly wish
to solve the cesarean birth rate problem or she is ignorant of the facts
as they exist. It would appear that her motives are political in nature.
Instead of attempting to seriously solve the problem, she is looking for
a scapegoat, and we all know who that will be.
Her plan to release this information to the public will not, as she is fully
aware, “foster a greater physician and patient communication on this
issue,” but will fuel additional public confusion and further destroy an
already tarnished physician-patient relationship.
She states that “a concerted effort must be made if we are to reduce
this rate to a more appropriate level.” I agree wholeheartedly. However,
if Dr. Coye and the state are truly interested in reducing the cesarean
birth rate in the state, then she would abandon this charade and address
the real cause for the high cesarean birth rates in this state and in the
country as a whole. The overwhelming reason why cesarean birth rates
are so high in this state is based solely on the horrendous medical-legal
situation that exists. I hope this comes as no surprise to Dr. Coye. Until
this problem is resolved, cesarean birth rates never will be significantly
reduced and may rise even higher. □ John R. O’Neal, MD
I appreciate the concerns of Dr. O’Neal and the time he has taken to
express his thoughts on this matter. I know that we both share the same
goal of healthy mothers having healthy babies.
However, I think it is important to clarify the goals of the c-section
reduction project and to point out the encouraging support and partici-
pation we have received from obstetricians, hospital administrators,
nurse midwives, nurses, insurers, and others who are part of the maternal
health care delivery system in New Jersey.
The rising rate of cesarean sections is due to a multitude of factors and
will not be stemmed, or ultimately reduced, by attempting to fix blame
on any one group, institution, or practice. The problem of obstetrical
liability has remained relatively constant for more than a decade, while
cesarean sections have increased markedly. In fact, the most successful
efforts to reduce the c-section rate specifically assist the physician in
providing clear protocols and opportunities for supporting opinions.
Clearly, the literature demonstrates that c-section reduction projects can
C-SECTION
REDUCTION
PROJECT
VOL. 87— NUMBER 2 FEBRUARY 1990
101
LETTERS & VIEWPOINTS
be developed and achieve marked success even in the absence of changes
to the malpractice system.
On December 12, 1989, the Department of Health and Blue Cross/Blue
Shield of New Jersey cosponsored a conference on improving pregnancy
outcomes. The conference focused on the rising c-section rate and exam-
ined the multiple factors responsible for increased rate. I am pleased to
say that the conference was well attended by obstetricians, hospital
personnel, and other key parties who have conducted a responsible,
objective review of the issue and will participate in formulating construc-
tive programs aimed at reducing the rate of cesarean births. During the
course of the conference, it was clear that no single group was the cause
of the problem, and that solving the problem will require the concerted
efforts of all these groups.
I want to assure you that it never has been my intention to look for a
“scapegoat” or to “fuel public confusion” about this issue. I do believe
that the public interest will be served through an open and honest
examination of the issue and a multidisciplinary approach to problem
solving. Obviously, patient education is critical in order to reduce this
source of pressure upon physicians to perform c-sections. Obstetricians
will need the support of their patients, hospitals, and peers, as well as
their malpractice carriers, if the number of medically unnecessary
cesarean sections performed in New Jersey is to be reduced. □ Molly
Joel Coye, MD, MPH
DO WE I applaud Dr. Edward G. Bourns, who has written in these pages, of
NEED PACs? his belief that PACs are not morally right, and who is uncomfortable
with physicians buying influence and votes through contributions to
state and federal legislators. The response of the president of our Society
in the same issue (volume 86, page 845) attempts to justify the contrary
position, borne of an intense sense of frustration with the manner in
which our profession is being treated, and accepting a philosophy of, “If
you can’t fight ’em, join ’em.” Since it is expensive to run a campaign,
he reasons, we have an obligation to send money to those candidates
whose election will assure friendly votes.
Surely, this is a subversion of the democratic ideal and visions of our
forefathers. To encourage the philosophy of a legislature for sale to the
highest bidder is to advocate the end of democracy. If PACs continue
unfettered, no matter how much money we give, control of the legislative
process will belong to those with more money and greater numbers than
the medical profession, and we will be as unsuccessful in promoting our
agenda as we are now, for we can be outspent by most of corporate
America, and the price of purchasing a legislator will rise beyond our
ability to pay.
Obviously, I believe we should do away with all PACs. Dr. Bourns and
I are naive in believing that physicians, through their traditional roles
as teachers, can stem the tide of political abuse and bring enlightenment
back to government. But, I submit, there is no ethical way that is
consistent with the ideals of our profession and that honors the values
and ideals used to set our country apart.
We, as physicians, individually and through our leadership, must grap-
ple with the dilemma of how best to deal with opponents who do not
play according to the rules we honor and respect. I submit that to step
down into the arena of political slugfest will demean and destroy our
professional standing and ethical reputations, as surely as we perceive
the present legislative process to be threatening the health of our patients
102
NEW JERSEY MEDICINE
LETTERS & VIEWPOINTS
and of our own finances. If we maintain the high road, we might lose
some battles in the long run, but we will win the wars. □ Robert A.
Goldstone, MD
WHY PACs The idea of contributing money to the election of our representatives
ARE NEEDED is anathema to many individuals, although it is a well-entrenched part
of the American scene.
Allow one with mixed feelings about the process to make some observa-
tions, without taking sides:
• Some of the motives ascribed to the president of our Society
are untrue and unwarranted, based on careful reading of the
President’s Page on page 845 of the November 1989 issue of
NEW JERSEY MEDICINE. This is unfair, to say the least.
• Many people believe in a free-market approach to include
PACs and other groups, as being in the American tradition.
• The United States Supreme Court already has struck down a
limit on spending as being an unconstitutional infringement of
free speech.
• Special interest money tends to continue flowing. Dam one
channel; another will open.
• Some feel that spending money to advertise one’s position to
candidates is not different from other ethical forms of advertis-
ing. (We can debate the overall ethics of advertising another
time.)
• Other proposals to assure better representation at all gov-
ernmental levels may be more productive. They include limited
terms of office, control of franking privileges, proscription of
dual-elected positions, etc.
The entire electoral process, including the legality of PACs, continues
to frustrate. This is not new; two generations ago Will Rogers said politics
had become “so expensive it takes lots of money to even get beat with.”
It would indeed be rewarding if we could always take the “high road”
and have merit receive its just reward, but “putting your money where
your mouth is” represents, to many, a cherished part of our culture. □
Howard D. Slobodien, MD, Editor-in-Chief
LETTERS TO Letters to the editor are welcome. Communications should be sent to
THE EDITOR NEW JERSEY MEDICINE, MSNJ, Two Princess Road, Lawrenceville,
NJ 08648.
VOL. 87— NUMBER 2 FEBRUARY 1990
103
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NEW JERSEY MEDICINE
Sexual Harassment
and Discrimination
Impact on Physical and Mental Health
DIANE K. SHRIER, MD
The Committee on Women of the New Jersey
Psychiatric Association recently has sur-
veyed materials in the literature and policies
and procedures from a number of New Jersey and
other corporate and academic programs relating to
sexual harassment and sexual discrimination in the
workplace, academia, and medicine. In educating
ourselves on this important issue, we became aware
of its widespread prevalence and the often serious
health (including psychiatric) consequences for its
victims. The American Psychiatric Association has
a position statement on sexual harassment and other
forms of gender-based employment discrimination.1
The American Medical Association’s House of Del-
egates recently approved a study on the per-
vasiveness of sexual harassment and sexual exploi-
tation of medical trainees by their faculty super-
visors and their resulting ethical, health, and psy-
chosocial problems.2 While sexual harassment and
sexual discrimination also is experienced by men
and by homosexuals, the vast majority of victims are
women. This article, therefore, will focus on the ex-
periences of women. Sexual harassment and sexual
discrimination will be defined. Its prevalence, com-
monly manifested physical and emotional symptoms
and syndromes, options available to victims and the
potential hazards associated with exercising these
options will be discussed. A partial list of resources
Dr. Shrier is professor of clinical psychiatry and director
of the Division of Child and Adolescent Psychiatry, De-
partment of Psychiatry, UMDNJ-New Jersey Medicai
School, Newark. Requests for reprints may be addressed
to Dr. Shrier, UMDNJ-New Jersey Medical School, Room
B60C, 215 South Orange Avenue, Newark, NJ 07103.
will be presented. We hope to alert New Jersey medi-
cal practitioners to this serious health problem, that
has many similarities to spouse abuse, sexual
molestation, and other victimization occurrences.
DEFINITIONS
Sexual discrimination in the workplace, pro-
hibited under the 1964 Civil Rights Act, is mani-
fested by differential hiring, work assignments,
salaries, promotions and other conditions of work
based on sex,35 including “exclusion from social and
peer networks in which business occurs, information
is shared, or decisions are made.”6
Sexual harassment is a specific type of sexual dis-
crimination. Harassment ranges from unwelcome
sexual advances such as pressure for dates, sexually
suggestive remarks, teasing, jokes, or gestures; re-
quests and pressure for sexual favors through words,
letters, or phone calls; and other verbal or physical
conduct of a sexual nature such as deliberate touch-
ing, cornering, pinching, actual or attempted rape,
or assault.6
PREVALENCE
While overt sex discrimination in the workplace
is much reduced since the 1960s, subtle and covert
discrimination persists; women continue to make, on
average, no more than 60 cents for every dollar men
earn. Women in university and in medical school
settings remain in the lower ranks of administration
and faculty levels and, on average, are paid substan-
tially lower salaries than men in comparable posi-
tions despite comparable academic performance.7
Sexual harassment is widespread and often severe
VOL. 87— NUMBER 2 FEBRUARY 1990
105
in nature. One of the best studies was a 1981 random
survey of federal government employees, where 85
percent responded. Of the more than 10,000 women
who replied, 62 percent reported having experienced
sexual harassment such as sexual touching and 20
percent reported actual or attempted rape or assault
on the job. Also, 42 percent reported that they had
been sexually harassed on the job in the two years
prior to the survey.6
IMPACT
Such widespread sexual discrimination and sexual
harassment against women in the workplace and
academia has significant and serious economic, psy-
chiatric, and stress-related health consequences.
Crull conducted a study at The Working Women’s
Institute of New York in 1981, using a nonrandomly
selected sample. Crull found 66 percent of the
women studied either had left jobs where they were
harassed (42 percent) or were fired (24 percent),
either as retaliation for complaining about the
harassment or because of deterioration of per-
formance as a consequence of the harassment.8
Another survey using a random-sample found 25
percent of the women studied either had changed
jobs under duress, endured adverse working con-
ditions, or suffered diminished opportunities for ad-
vancement as a consequence of sexual harassment.6
Whether or not women left or lost their jobs due
to sexual harassment, the stress-related effects on
job performance, emotional well-being, and physical
health were pervasive and debilitating. In the
nonrandom survey of clients of The Working
Women’s Institute of New York, 75 percent of the
women reported adverse effects on their job per-
formance, such as: inability to concentrate, reduc-
tion in confidence in their skills and accomplish-
ments, and loss of motivation due to retaliation for
their refusal to make themselves sexually available.8
Ninety percent of the sample and 95 percent of a
prior preliminary survey conducted by The Working
Women’s Institute reported psychological stress
symptoms such as general tension or nervousness,
persistent anger, fear, and helplessness.9 Such symp-
toms resemble those found in victims of incest, rape,
and other traumatic experiences. Some of the
psychological effects include symptoms also found in
the following DSM-IIIR diagnoses: post-traumatic
stress disorder; major affective disorder, depressive
type; dysthymic disorder; and adjustment dis-
order.10 Some women experience flashbacks, re-
awakening of memories, and reactive physical and
emotional symptoms of prior experiences of vic-
timization. When one considers that more than 40
percent of women in Russell’s well-designed random
survey reported having been victims of sexual abuse,
rape, or incest prior to age 18 with similarly high
rates in adult life, one can see how sexual harass-
ment experiences could compound prior victimiza-
tion effects for a large number of women.11
Table. Additional Resources.
The Association of American Medical Col-
leges Women in Medicine Coordinating Com-
mittee, One Dupont Circle, NW, Washington,
D.C. 20036. Developed an annotated bibliog-
raphy on sexual harassment useful for both the
woman victim and the health care practitioner.
Jean Hamilton, MD, Institute for Research on
Women's Health, 1616 18th Street NW, Washing-
ton DC 20009. Coordinated additional infor-
mation on sexual harassment and discrimination
and recommendations on working with knowl-
edgeable attorneys.
The Association of Women Psychiatrists,
University of Louisville School of Medicine,
Louisville, KY 40292. Established a legal network
of members with particular interest and ex-
pertise in areas of forensic psychiatry relating to
women.
Committee on Women of the New Jersey
Psychiatric Association, 1394 Mt. Vernon
Road, Bridgewater, NJ 08807. Members Drs.
Rose Prystowsky, Annette Hollander, Jane
Sofair, and Diane Shrier compiled the infor-
mation used in this paper and would be available
as resources.
Sixty-three percent of Crull’s sample reported
physical symptoms associated with the sexual
harassment, most commonly nausea, headache, and
chronic fatigue.8 A number of these women sought
medical consultation for their symptoms, but they
rarely were identified as being related to their
adverse job experiences. Increased use of alcohol and
other prescription or nonprescription drugs may
occur in efforts to reduce stress-related symptoms.
A number of research studies have confirmed the
adverse stress-related health effects of various life
changes. Eight items of the 43-item “Social Re-
adjustment Scale” developed by Holmes pertain to
employment effects commonly experienced by sex-
ual harassment victims.12 These include: major
change in working hours or conditions; troubles with
the boss; major change in responsibilities at work;
changing to a different line of work; major change
in financial state; major business readjustment; re-
tirement from work; and being fired.
OPTIONS AND THEIR EFFECTS
Many corporate, university, and medical institu-
tions have specific policies and procedures in regard
to sexual harassment and sexual discrimination.
106
NEW JERSEY MEDICINE
However, women attempting to report incidents of
sexual harassment all too often have had a com-
pounding of the adverse job, physical, and mental
health effects of the original victimization ex-
periences. When one becomes a “whistle-blower,”13
the institution is likely to defend itself in a variety
of ways including: denying that harassment oc-
curred, or denying that it was intentional, or claim-
ing that the woman brought it on herself, or insisting
that the positive attributes of the harasser outweigh
the impact of the harassment and, thus, action
should not be taken.1 2 3 4 5 6 Coworkers typically refuse
to come forward with corroborating information
previously given in private. Retaliation against the
victim by her superiors for reporting sexual harass-
ment is likely to occur with devaluing and criticizing
of her work and reassigning important work to
others, leading to an often increasingly intolerable
work situation. Family and friends typically
“blame” the victim, disbelieve her, and fail to sup-
port her efforts to fight against sexual harassment.3
The added stress and strain, that typically fol-
low the reporting of sexual harassment, are likely to
increase the emotional and physical health hazards
of the original victimization. The physician or coun-
selor to whom the woman turns for help must be
particularly careful not to confuse the effects of the
victimization with its causes. The patient may ini-
tially present with intense affective and behavioral
symptoms and “may appear extremely unstable,
histrionic, paranoid, or depressed.”3 These symp-
toms are common responses to severe harassment
and discrimination. Empathy, validation of the
woman’s experience, and helping her to resist de-
valuing herself are important first steps in reversing
the adverse effects. Identifying the source of the
physical and emotional symptoms as a reaction to
sexual harassment and discrimination can be useful,
as well as exploring the impact of such experiences
on marital and family life.
Referral for individual and/or group supportive
counseling to psychiatrists or other mental health
practitioners with expertise in this area can also
prove helpful. Interventions by the therapist should
be active and supportive and should provide infor-
mation about common emotional, physical, eco-
nomic, and family effects of harassment, the vic-
tim’s options for dealing with this situation, and the
potential risks associated with doing so. The thera-
pist needs to encourage the woman to develop con-
structive assertive coping approaches and to avoid
inappropriate angry and hurt reactions in the work-
place which might increase the likelihood of “victim-
blaming” by coworkers and superiors. Continuing
assessment of supportive relationships and the ef-
fects of the experience on family is important, as is
monitoring the woman’s use of maladaptive ap-
proaches to stress management, such as the inap-
propriate use of alcohol or prescription or non-
prescription drugs.3 A psychiatric or other medical
practitioner or mental health counselor may need to
give additional support to the victim of sexual
harassment by providing expert testimony in court.
SUMMARY
Sexual harassment and sexual discrimination con-
tinue to be pervasive problems for women in busi-
ness, academia, and medicine, with widespread and
often serious health, emotional, and economic conse-
quences. It is important that health care providers
become aware of the common physical and emo-
tional symptoms associated with these victimization
experiences and serve as supportive and informed
resources to their patients. ■
Submitted: April 1989;
Accepted: September 1989
REFERENCES
1. Hamilton JA: Position statement of sexual harass-
ment and other forms of gender-based employment dis-
crimination as significant occupational stressors. Sub-
mitted to the Occupational Psychiatry Committee of the
American Psychiatric Association, 1987.
2. Symonds A: News for women in psychiatry. Associa-
tion for Women in Psychiatry 7:8, 1989.
3. Hamilton JA, Alagna SW, King LS, Lloyd C: The
emotional consequences of gender-based abuse in the
workplace: New counseling programs for sex discrimina-
tion, in Brande N, Women, Power, and Therapy. New
York, NY, Haworth Press, 1987, 155-182.
4. Pendergrass VE, Kimmel E, Joesling J, et al.: Sex
discrimination counseling. Am Psychologist 31:36-46,
1976.
5. Dolkart JL: Discrimination on the job, in Burnett
BA, Every Woman’s Legal Guide. New York, NY, Double-
day, 1983, pp. 277-316.
6. U.S. Merit Systems Protection Board: Sexual
Harassment in the Federal Workplace: Is It a Problem ?
Washington, DC, U.S. Government Printing Office, 1981.
7. Symonds A: News for women in psychiatry. Associa-
tion for Women in Psychiatry 6:2, 1988.
8. Crull P: The stress effects of sexual harassment on
the job. Am J Orthopsychiat 52:539-544, 1982.
9. The Working Women’s Institute: Sexual harassment
on the job: Results of a preliminary survey. Research
Series, Report No. 1. New York, NY, The Working
Women’s Institute, 1975.
10. Diagnostic and Statistical Manual of Mental Dis-
orders Third Edition. Washington, DC, American Psy-
chiatric Association, revised 1987.
11. Russell DEH: Sexual Exploitation, Rape, Child
Sexual Abuse and Workplace Harassment. Beverly Hills,
CA, Sage Publications, 1984.
12. Holmes TH: Life situations, emotions, and disease.
Psychosomatics 19:747-754, 1978.
13. Glazer M: Ten whistleblowers and how they fared.
Hastings Center Report 12:33-40, 1983.
VOL. 87— NUMBER 2 FEBRUARY 1990
107
MEDICAL HISTORY
Mesmer and
His Critics
DANIEL PARISH
The Medical History Society of New Jersey awarded the Stephen Wickes
Prize in the History of Medicine to this original essay on Franz Anton Mesmer.
Mesmer, the controversial Austrian doctor, was known for his theory of
animal magnetism.
Few characters in history are as controversial
as the Austrian doctor Franz Anton Mesmer.
His theory of animal magnetism, that there
is a universal fluid which is the determinant of all
health, made him one of the most popular and most
vilified doctors in late 18th century Europe.
Mesmer appears as a misguided researcher at
best, and as a greedy charlatan at worst. He is a
physician who probably plagiarized his medical dis-
sertation, and a discoverer whose greatest contribu-
tion was “to give a name [animal magnetism] to a
supposed occult influence about which many others
had written.”1
But if Mesmer was derivative, somewhat dis-
honest, and largely wrong, his 18th century detrac-
tors often were no better, and, on occasion, were
worse. The pompous members of the great Austrian
and French medical and scientific societies did not
reject Mesmer as much for his beliefs as they did
for his challenge to their hegemony.
Requests for reprints may be addressed to Daniel Parish,
941 Bryn Mawr Avenue, Penn Valley, PA 19072.
Mesmer was born on May 23, 1734, in the small
German town of Iznang on Lake Constance. His
early education was in Jesuit institutions, and his
first degree, received in 1755 from the University of
Ingolstadt, was in theology. Mesmer’s activities be-
tween 1755 and 1759 are unknown, but by the time
he entered the LIniversity of Vienna in 1759, he was
ascribing to himself the title of Doctor of Philosophy.
It is uncertain that he actually earned this title.2
He pursued a degree in law for a year before finally
deciding to become a physician, and then spent the
next six years studying medicine. Despite prevailing
trends in the University away from “cosmic” medi-
cine, Mesmer became fascinated with the stars and
astronomy and read the works of Paracelsus ex-
tensively. In 1766, he wrote his medical dissertation,
“The Influence of the Planets on the Body,” a work
which reflected these interests. The dissertation,
however, totals only 48 unremarkable pages, and, if
not actually plagiarized, was highly unoriginal.2 His
central thesis was a virtual replication of Richard
Mead’s 1794 treatise; for example, 22 of Mesmer’s
23 clinical studies were drawn from Mead’s work,
108
NEW JERSEY MEDICINE
MEDICAL HISTORY
although they were not attributed to it. Regardless,
“none of the medical faculty considered his ideas
seriously,” and Mesmer did not attract much atten-
tion until 1774. 3
Mesmer’s discovery of animal magnetism came
between 1774 and 1775. Working on his theory of
“animal gravity” as developed in his dissertation,
Mesmer became impressed with the work Father
Hell, a professor of astronomy at the University of
Vienna, had done with loadstones (magnets) and
wanted to use them for his own experiments.
Mesmer believed a single universal fluid was the
source of all health, and that a magnet could control
the fluid’s influence on disease; he had discussed
this in his dissertation. This fluid supposedly flowed
undisturbed through healthy people but moved im-
properly or was congested in the sick. The final goal
of his medical treatment was to restore the normal
flow of this fluid. Before a patient could be cured,
he would have to be overwhelmed with an excite-
ment of the fluids within him, much like having a
dam burst within the patient. This would result in
a violent quickening of the disease (called a ‘crisis’),
a momentary surge of pain or a fit, and then calm.
Hell agreed to supply Mesmer with magnets. His
thesis, “there is only one illness and one cure,”
directed his work from 1774 onwards.4
Mesmer also had been consulting with J.J.
Gassner, a Swabian faith healer, and learned that
one did not need magnets to control the flow of this
fluid. This discovery finally induced Mesmer to
change his theory from ‘mineral’ to ‘animal’
magnetism.
Mesmer’s first successful use of magnets and
animal magnetism was on Franzl Oesterlin. Begin-
ning in 1773, he treated her and observed her crises
and eventual recovery. In a letter dated January 25,
1775, he announced for the first time that he had
confirmed the existence of animal magnetism, but
he did not publish his seminal work, “On the Dis-
covery of Animal Magnetism,” until 1779.
The Viennese Faculty of Medicine, which looked
upon Mesmer’s associations with Hell and Gassner
as distasteful, was alarmed at his new method of
treatment, which to them wreaked of spiritualism
and the occult. The Faculty was determined to ex-
pose Mesmer; they could not expel him from Vienna,
but pressured him to leave for Paris in 1778, after
his well-publicized attempt to treat a blind pianist,
a protege of the Empress Maria Theresa, failed.3
Mesmer’s arrival in Paris was soon followed by an
invitation from the Academy of Science to present
his theory before them. This monolithic body, which
had dominated French scientific life since 1666, de-
cided both he and it were worthless. Following this
failure, Mesmer invited patients to a retreat at
Creteil and offered to present the results of his treat-
ments there to the Academy. This failed to win of-
ficial approval. Finally, Mesmer won over one mem-
ber of the Faculty of Medicine, Charles Deslon.
After that first conversion, Mesmer and his the-
ories rapidly achieved an immense popularity.
Deslon gave Mesmer an inroad to the Queen, Marie
Antoinette, who came to believe in animal
magnetism and thereby gave the theory a vogue at
court. Mesmer then published the popular “On the
Discovery of Animal Magnetism.” Mesmer captured
the attentions of the salon set in Paris.
While the major scientific authorities were con-
vinced that Mesmer was a fraud, more and more
people came to regard him as a medical savior. He
did spectacular things and, often enough, had spec-
tacular results, but this had little to do with the
magnets and everything to do with the power of
suggestion. Mesmer’s growing band of wealthy and
powerful supporters, however, did not know or care.
The controversy came to a head in 1784. Mesmer
and animal magnetism had become the rage of
Paris, arousing even more excitement than the first
hot air balloon flight in 1783. The Journal de Brux-
elles went so far as to speculate that mesmerism
“soon will be the sole universal medicine.”6
In March, Louis XVI ordered a commission set up
to investigate animal magnetism. The commission
was composed of men no less famous than Mesmer
himself. On it sat five members of the Faculty of
Medicine of Paris and five of the Royal Academy of
Sciences. The king also allowed the Royal Society
of Medicine to establish a board and make a report.
The Society, a younger rival of the more prestigious
Faculty, wanted its own say, and it was simply easier
to let them have it.
M. Thouret of the Royal Society, for example, had
already written a book condemning Mesmer, and he
was out for blood. Indeed, the official reason for the
report was that Deslon had been threatened with
expulsion from the Faculty of Medicine. And for that
reason, committee members did not actually in-
vestigate Mesmer, but rather they challenged
Deslon. Mesmer, in fact, was absent at his own trial.
The first step of the committee was to investigate
the baquet of Deslon and to see how it worked. When
they decided that the confusion of 50 or so people
being magnetized and in crisis would be uncon-
ducive to scientific investigation, they had Deslon
come to commission member Benjamin Franklin’s
house in Passy, outside of Paris, to show his treat-
ments. Fourteen sick individuals “such as could not
be suspected of sinister views”7 were brought there
and treated with magnetism. Of the 14 persons, only
5 persons said that they felt anything at all. The
commissioners then rationalized the 5 persons as
false anyway, even declaring one person to be a poor
man who probably “thinks he shall contribute more
VOL. 87— NUMBER 2 FEBRUARY 1990
109
MEDICAL HISTORY
to our satisfaction by professing to experience sen-
sations of some kind.”7
The next round of experiments took place at the
home of M. Jumelin, neither a student of Mesmer
nor Deslon, but one who professed to understand
animal magnetism. Experiments on eight men and
two women failed to produce any positive results.
Back at Franklin’s house, the commissioners had
Deslon magnetize one tree. A boy then was led to
four other unmagnetized trees. At each tree, he be-
came successively worse until falling into a crisis.
When the boy was led to the magnetized trees after
recovering, he felt nothing. The commissioners also
presented a tray full of china bowls to a woman; she
had been told some of the bowls had been
magnetized (none of them actually had been). She
picked up four bowls in succession. When she held
the second one, she began to feel symptoms. After
grasping the fourth, she fell into a crisis. The com-
missioners offered her a drink of water from another
bowl to relax her. From this one, which had been
magnetized, she drank without difficulty.
After a few more experiments, a published report
condemned animal magnetism. A secret second one,
written for the king’s eyes only by the same group,
declared mesmerism to be morally repugnant and
dangerous. A third one, prepared by members of the
Royal Society of Medicine’s commission, attacked
animal magnetism too. All conclusions were similar:
“Compression, imagination, and imitation are there-
fore the true causes of the effects attributed to this
new agent, known by the appellation of animal
magnetism.”7
Yet, it is an overstatement to declare Mesmer’s
“fate as a scientist was sealed, and his theories dis-
credited.”s In a letter to Jan Ingenhousz dated April
29, 1785, Franklin wrote, “Mesmer continues here
and has still some adherents and some practice. It
is surprising how much credulity still subsists in the
world. I suppose all the physicians in France put
together have not made so much money during the
time he has been here, as he has done.”9 Hundreds
of pamphlets from supporters defending Mesmer
and animal magnetism and attacking the com-
mission report appeared in 1784 and 1785. Though
the committee was not nearly as dishonest as some
critics have implied, it was biased. The report had
not denied Mesmer’s successes, but only his concept
of disease. In 1831, a second committee investigating
animal magnetism would concede suggestion and
the trance as useful to medicine, but in 1784, no such
leap could be made by either side.
Mesmer’s influence and popularity crested in
1784. Eight years later he left Paris, the great fortune
he had accumulated in his heyday having been
largely dissipated, and returned to Lake Constance,
where he remained until his death on March 5, 1815.
Animal magnetism, and the new term “mes-
merism,” did not fade away. Elisha Perkins aroused
a great furor in the United States in the 1790s with
a remarkable device called a tractor and “a stroking
reminiscent of Mesmer’s animal magnetism.”10
Mesmerism was carried on by the Society of Har-
mony in France and experienced a revival in Britain
in the 1840s and 1850s. By the late 1800s, however,
animal magnetism already had lost much of its orig-
inal meaning.
Although animal magnetism and mesmerism ap-
pear pseudoscientific today, they were grounded in
enough science to be accepted by many as scien-
tific— not all the followers were quacks. Newton
himself had pondered over a “subtle spirit” which
pervaded all things, and many doctors, including
some on the commission, believed this. There was
something important in what Mesmer was doing,
but the commission, in its haste to condemn him,
overlooked the fact that many had been cured; the
discovery of hypnosis had to wait 60 years. Most
criticized Mesmer on the basis of his deviance from
scientific dogma which had many faults of its own.
To a large degree, the academies had replaced the
papacy in condemning scientific heresy. Arrogance
and jealousy, not a search for rational truth, were
the greatest contributing factors to Mesmer’s de-
cline. ■
Submitted: October 1988;
Accepted: September 1989
REFERENCES
1. Horine EF: Charles Caldwell, MD. Brooks, KY, High
Acres Press, 1960.
2. Pattie FA: Mesmer’s medical dissertation and its
debt to Mead’s de imperio solis ac lunae. Hist Med
11:276-281, 1956.
3. Wyckoff J: Franz Anton Mesmer: Between God and
Devil. Englewood Cliffs, NJ, Prentice Hall, 1975.
4. Mesmer FA: Maxims on Animal Magnetism. Mt.
Vernon, NY, The Eden Press, 1957.
5. Walmsley DM: Anton Mesmer. London, England,
Robert Hale, 1967.
6. Darnton R: Mesmerism and the End of the Enlight-
enment in France. Cambridge, MA, Harvard, 1968.
7. Report of Dr. Franklin and other Commissioners.
London, England, J. Johnson, 1785.
8. Hahn R: The Anatomy of a Scientific Institution:
The Paris Academy of Sciences, 1666-1803. Berkeley, Uni-
versity of California, 1971.
9. Smyth AH: The Writings of Benjamin Franklin. New
York, NY, MacMillan, 1906.
10. Quen J: Elisha Perkins, physician, nostrum vendor,
or charlatan? Bulletin Hist Med XXXVII: March-April,
1963.
110
NEW JERSEY MEDICINE
Spacer-Induced
Atrial Fibrillation
CHRISTOPHER C. BREEDEN, MD
BENJAMIN H. SAFIRSTEIN, MD
Inhaled sympathomimetics, studied extensively for treatment of asthma, have
been found to be safe from cardiac arrhythmias. We discuss a case report
of albuterol used with a spacer device that induced atrial fibrillation. We
review relevant literature.
An asthmatic patient today has more thera-
peutic options available than ever before.
Various oral medications often are com-
bined with inhaled medications. Of the inhaled
agents, albuterol has gained great acceptance and
enjoys a prominent position in the treatment of
asthma. We recently treated a patient who de-
veloped atrial fibrillation following the use of in-
haled albuterol using a spacer, a study we have not
found reported in the literature.
CASE REPORT
A 26-year-old male with a four-year history of in-
termittent asthma noted the onset of shortness of
breath one evening. He treated himself with two
puffs of albuterol via a metered dose inhaler using
the spacer device, InspirEase". The cough and dys-
pnea improved, but he noted the onset of palpita-
tions when he retired. Upon arising the following
day, he was nauseated and mildly diaphoretic, and
still had palpitations. An electrocardiogram demon-
strated atrial fibrillation. He was treated with a
beta-blocker, InderaP. A short time later, his
Dr. Breeden is a pulmonary fellow and Dr. Safirstein is
director of pulmonary medicine, Saint Michael’s Medical
Center, Newark. Requests for reprints may be addressed
to Dr. Safirstein, Saint Michael's Medical Center, 268
Martin Luther King Jr. Blvd., Newark, NJ 07102.
palpitations ceased; and repeat electrocardiogram
showed a return to normal sinus rhythm. Other such
episodes occurred following the use of albuterol with
a spacer device. Medical evaluation, including
thyroid profiles, Holter cardiac monitoring, echocar-
diography, and a cardiac stress study, was normal.
Pulmonary function studies demonstrated mild vari-
able airflow obstruction. No other oral or inhaled
medications were used and he had no significant
past cardiac history. He discontinued the spacer de-
vice but continued albuterol via a metered dose in-
haler (MDI) without return of palpitations or ar-
rhythmias. An exercise study with cardiac monitor-
ing failed to document any ischemic changes or ar-
rhythmias, either with or without inhaled albuterol.
REVIEW
Atrial fibrillation is an unstable cardiac ar-
rhythmia that had not been reported to occur with
inhaled bronchodilators. In 1967, Lands et al.' sug-
gested the existence of a specific beta-2 receptor
causing predominantly bronchodilation; since then
many agents have emerged and provided thera-
peutic alternatives for bronchospastic disorders.
Albuterol, a synthetic catecholamine, has been used
widely since its introduction in 1968. It demonstrates
a prolonged duration of action and more bronchial
specificity when compared to its forerunners
VOL. 87— NUMBER 2 FEBRUARY 1990
113
isoproterenol, isoetharine, and epinephrine. Many
studies have substantiated this; no studies found
any serious cardiac stimulation.
In a study of 15 steroid dependent asthmatics,
Safirstein et al.1 2 3 found no alteration in pulse, blood
pressure, or rhythm following single oral doses of 4
mg and 6 mg albuterol tablets. Tattersfield et ah,
in a double-blind trial, found no increase in heart
rate with inhaled albuterol unless given five times
the recommended dose.1 Shim et al.4 found no in-
crease in arrhythmia using inhaled isoproterenol ex-
cept for one patient who developed atrial fibrillation
while receiving concurrent intravenous amino-
phyllin. Montenegro et al.5 found a higher, though
not statistically significant, incidence of atrial
premature beats during pulmonary function testing
using inhaled isoproterenol compared to isoetharine.
Respiratory maneuvers are known to alter cardiac
rhythm by slowing arteriovenous conduction and
sino-atrial activity. These effects are mediated via
vagal afferants in the viceral pleura, stimulated at
total lung capacity and vagal efferrents innervating
the heart. Lamb et al.6 demonstrated these effects
and had one case of AV dissociation with nodal
tachycardia which had rapid spontaneous resolu-
tion.
It is improbable that atrial fibrillation occurred as
a result of the propellant. Freon and other
fluorocarbons are known to depress myocardial con-
tractility, alter conduction, and lower the threshold
of myocytes to the arrhythmogenic effects of sym-
pathomimetic amines; it is estimated that in vivo
this would take 12 to 24 consecutive breaths to see
such an effect.7 8
The widespread difficulties with patient com-
pliance in using metered dose inhalers have led to
the use of an inhalation aid called spacers. Spacers
act either as holding chambers for the aerosol spray
or as devices which prolong the aerosol time within
the spacer, thus reducing oropharyngeal deposition.
Tube spacers are simple devices which reduce the
amount of medication deposited at the oropharynx
from 80 to 4 percent.13 Spacers with holding
chambers, such as the one used by our patient, vary
in capacity from 140 ml to 600 ml. Because these
spacers allow more time for evaporation of the
propellant, particle size becomes smaller and, thus,
more aerosol is deposited on the smaller airways.15
It is our contention that albuterol triggered atrial
fibrillation in our otherwise healthy young asthmatic
principally through the increased dose available by
using the spacer. These episodes of palpitations
ceased when the metered dose inhaler was used
without the spacer; the patient still was able to
obtain symptomatic relief. Cardiac beta receptors
predominately are beta-1, but up to 20 percent have
been reported to be beta-2 receptors.9 * This may ac-
count for wide variability in cardiac stimulation.
With the increasing use of spacers and improved
means of delivering bronchodilaters to the en-
dobronchial system, closer observation for cardiac
arrhythmias should be undertaken.
CONCLUSION
A healthy 26-year-old male with asthma de-
veloped repeated episodes of atrial fibrillations using
albuterol via a metered dose inhaler with a spacer.
No such episodes occurred when the spacer was dis-
continued. We postulate arrhythmias may result
from increased deposition of the sympathomimetic
drug albuterol when used with a spacer. ■
Submitted: May 1989;
Accepted: August 1989
REFERENCES
1. Lands AM, Arnold A, et al.: Differentiation of recep-
tor systems activated by sympathomimetic amines.
Nature 214:597-598, 1967.
2. Safirstein BH, et al.: Bronchodilator effects of oral
salbutamol and theophylline combinations in chronic ster-
oid dependent asthmatics. J Med Soc NJ 76:892-894, 1979.
3. Tattersfield AE, McNichol MW: Salbutamol and
isoproterenol. N Engl J Med 218:1323-1326, 1969.
4. Shim CS, et al.: Effect of bronchodilator agents on
arrhythmias. NYS J Med 11:1973-1976, 1976.
5. Montenegro A, et al.: Cardiac arrhythmia during
routine tests of pulmonary function in patients with
chronic obstruction of airways. Chest 73:133-139, 1978.
6. Lamb LE, Dermksian A: Significant cardiac ar-
rhythmias induced by common respiratory maneuvers.
Am J Cardio 11:563-571, 1978.
7. Drug Therapeutics Bull 14:6, 1976.
8. Newman SP, et al.: Effect of InspirEase® on the
deposition of metered dose aerosols in the human respir-
atory tract. Chest 89:551-556, 1986.
9. Product information: Proventil®. Schering Corp.,
Kenilworth, NJ, 1987.
10. Warrell DA, et al.: Comparison of cardiorespiratory
effects of isoproterenol and salbutamol in patients with
bronchial asthma. Br Med J 1:65-70, 1970.
11. Goodman LS, Gillman A: The Pharmacological
Basis of Therapeutics. NY, New York, Macmillian Pub-
lishing Co., 160-173.
12. Webb-Johnson DC: When drug therapy for lung
disease affects the heart. Geriatrics 11:79-87, 1976.
13. Newman SP, Pavis D, Garland N, et al.: Effects of
various inhalation modes on the deposition of radioactive
pressurized aerosols. Eur J Respir Dis 63:57-65, 1982.
14. Silverglade A: Cardiac toxicity of aerosol
propellants. JAMA 222:827-829, 1972.
15. Ahmad D: Effects of aerosol propellants in airway
function, in Epstein A (ed): Metered Dose Inhalors/An
International Workshop. Mississauga, Ontario, Astra
Pharma Inc., 1984, pp. 22-26.
114
NEW JERSEY MEDICINE
Medical Waste
Regulations
EDWARD A. HOGAN, ESQ.
Joseph j. mcgovern, esq.
Medical waste generators are subject to federal and state waste tracking and
reporting regulations. Failure to comply with regulations can result in the
imposition of significant penalties.
Medical waste management and disposal
have become environmental and health
priorities. Legislators have responded to
the public’s increased attention to these issues by
enacting legislation expanding existing medical
waste regulatory programs. Medical waste gener-
ators, transporters, intermediate handlers, and dis-
posal facilities now have extensive regulatory obli-
gations and can be subject to substantial penalties
for noncompliance. This article will highlight those
regulatory obligations that apply to medical waste
generators.
Mr. Hogan and Mr. McGovern are affiliated with the De-
partment of Environmental Law, Porzio, Bromberg &
Newman, P.C. Requests for reprints may be addressed
to Mr. McGovern, Porzio, Bromberg & Newman, 163
Madison Avenue, Morristown, NJ 07962-1997.
PRIOR MEDICAL WASTE REGULATION
Until recently, the only regulation of medical
waste management consisted of weak state level re-
strictions. The New Jersey State Department of
Health (NJDOH) has restrictions for the on-site
handling and treatment of pathological and infec-
tious wastes. Traditionally, medical waste was
classified into two categories: infectious (pathologi-
cal) and noninfectious. Infectious waste includes
such materials as liquid or solid microbiological cul-
ture media, needles, syringes, and sharps; pathology
specimens, including tissues, organs, body parts,
and products of conception; bulk blood; blood prod-
ucts, and body fluids. Noninfectious waste includes
all other solid and nonrigid medical waste (including
office paper products and food waste). NJDOH regu-
lations are facility specific; that is, NJDOH has indi-
VOL. 87— NUMBER 2 FEBRUARY 1990
115
Highlights of Medical Waste Generator
Regulatory Obligations
1 . Segregate: Sharps, fluids, other medical waste.
2. Package: Rigid, leakproof, impervious, tear or burst resistant, sealed.
3. Storage (if applicable): Protect from elements, prevent access, refrigerate (if
necessary).
4. Label: Biohazard symbol or other.
5. Mark: Water resistant tag including generator information/other.
6. Tracking Form: Complete according to state specifications and retain copies.
7. Logs: Daily or monthly depending on waste generation rate.
8. Annual Report: Summary of medical waste activity.
vidual regulations for different types of health care
facilities. For example, NJDOH has separate regu-
lations governing the on-site handling and treatment
of medical waste at residential health care facilities,
homes for sheltered care, ambulatory care facilities,
and hospital facilities.1 Generally, NJDOH medical
waste management regulations require that the
health care facility properly treat (i.e. autoclave or
incinerate) infectious waste to render it noninfec-
tious and destroy solid sharp or rigid items, or dis-
pense of them in appropriate containers. NJDOH
regulations do not extend to every possible generator
of medical waste. Furthermore, NJDOH regulates
medical waste only at the point of generation.
NJDOH does not regulate medical waste once it has
left the health care facility for disposal. Regulation
of the transportation and disposal of medical waste
is under the authority of the New Jersey Department
of Environmental Protection (NJDEP).
Medical waste management previously was gov-
erned by the NJDEP solid waste regulatory program
which established a broad framework within which
all solid waste activity (i.e. collection, disposal, and
utilization) is coordinated.2 The specific require-
ments for solid waste activity depend upon the
classification of waste, each class or type of waste
being regulated differently. NJDEP devised the fol-
lowing waste classification scheme under the solid
waste management regulations: Type 10, municipal;
Type 12, dry sewage sludge; Type 13, bulky waste;
Type 23, vegetative waste; Type 25, animal and food
processing waste; and Type 27, dry industrial waste.
Medical wastes were grouped with all other “munici-
pal” wastes, a class defined to include waste ma-
terial originating from schools, hospitals, research
institutions, and public buildings.3 Thus, NJDEP
always treated medical waste (including infectious
waste that had been rendered noninfectious in ac-
cordance with NJDOH standards) as common mu-
nicipal waste. NJDEP never identified medical
waste as an environmental concern until recently.
To the contrary, NJDEP relied on NJDOH regu-
lations as providing the necessary control over the
environmental and public health concerns as-
sociated with handling and treatment of medical
waste.
In addition to NJDOH and NJDEP regulations,
New Jersey has a statute that specifically governs
the handling of disposable or reusable hypodermic
needles or syringes. The New Jersey Legislature
adopted procedures for the disposal of certain nee-
dles and syringes, codified at N.J.S.A. 2A:170-25.17.
The statute states as follows:
No person shall discard or abandon in any
public or private place accessible to any
other person, whether or not the other per-
son may be a trespasser, any disposable or
reusable hypodermic needle or syringe,
without first destroying the needle or sy-
ringe; nor shall any owner, lessee, or other
person in control of premises accessible to
any other person, whether or not the other
person may be a trespasser, knowingly per-
116
NEW JERSEY MEDICINE
mit discarded or abandoned hypodermic
needles or syringes to remain on said
premises in an intact condition.
For purposes of this act, a hypodermic nee-
dle or syringe shall be deemed destroyed
only if: a. the needle is broken from the hub
or mangled, in the case of a needle, and the
nipple of the barrel is broken from the bar-
rel or the plunger and barrel are melted, in
the case of a syringe; or b. it is discarded
as a single unit, without recapping, into a
rigid container and the container is de-
stroyed by grinding or crushing in a com-
pactor, or by burning in an incinerator ap-
proved by the Department of Environmen-
tal Protection, or by any other method ap-
proved by the Department of Health.
The statute establishes methods for disposing of
certain needles and syringes and failure to follow the
procedures in the statute is considered a disorderly
persons offense. A violation is punishable by a fine,
not to exceed $500, or imprisonment (not more than
five days), or both. Many of the NJDOH regulations
incorporate this statute by reference.
LEGISLATIVE DEVELOPMENTS
Both Congress and the New Jersey Legislature
have been actively responding to the medical waste
crisis. The Medical Waste Tracking Act of 1988 was
adopted by Congress and signed into law by former
President Reagan.4 This Act amends the federal
Solid Waste Disposal Act and establishes a demon-
stration cradle-to-grave tracking program for medi-
cal waste. The states included in the demonstration
project are New York, New Jersey, and Connecticut,
and states bordering the Great Lakes. Under this
statute, the Environmental Protection Agency
(EPA) is directed to promulgate regulations to es-
tablish a tracking program for medical waste.
New Jersey has taken independent legislative
initiative in this area. On March 6, 1989, Governor
Kean signed the Comprehensive Regulated Medical
Waste Management Act (“Comprehensive Act”)
into law.5 Like the federal Act, the Comprehensive
Act requires that all “regulated medical waste” be
accompanied by a manifest completed by the gener-
ator, transporter, and disposal facility. However, the
state Act goes beyond the scope of the federal legis-
lation in that the state Act also requires regulated
medical waste generators to register with NJDEP,
maintain records of manifest activities, and perform
annual reporting of manifest activities. The Com-
prehensive Act also severely limits disposal options;
it requires all regulated medical waste be in-
cinerated or disposed of in a manner approved by
NJDEP. Regulated medical waste cannot be dis-
posed in a sanitary landfill unless disinfected and,
thereby, rendered noninfectious. Any violation is
punishable by a fine of up to $50,000 per day.
Both the federal and state legislation are modeled
after an existing cradle-to-grave tracking system
used for hazardous waste. The hazardous waste
manifest system has been operating for many years
and has proved effective in controlling the illegal
disposal of hazardous waste. Regardless of whether
or not medical waste truly presents a public health
threat, legislators believe that this proved tracking
system is the most feasible means of regulating the
medical community.
REGULATORY DEVELOPMENTS
In response to the public concern over medical
waste, NJDEP first issued emergency regulations on
August 10, 1988. It was NJDEP’s opinion that the
New Jersey Solid Waste Management Act (N.J.S.A.
13:1E-1 et seq.) provided sufficient authority for the
emergency action. NJDEP implemented an interim
medical waste tracking program until June 1989.
Under the Comprehensive Act, NJDEP was given
the specific mandate to adopt medical waste track-
ing regulations that mirrored the EPA demon-
stration program. On June 26, 1989, NJDEP issued
its second emergency adoption.6 NJDEP, concurrent
with the emergency adoption, proposed that the
regulations be readopted in compliance with normal
rule-making procedures. NJDEP formally adopted
the regulations on August 25, 1989, and the regu-
lations will not expire until November 4, 1990. The
most recent emergency regulations are a significant
expansion of the prior adoption. Specifically,
NJDEP has reclassified the types of medical waste
regulated, increased the tracking, logging, and re-
porting requirements, and eliminated the small
quantity generator exemption.
The regulations apply to the generation, storage,
transport, transfer, treatment, destruction, disposal,
or other management of “regulated medical waste”
in New Jersey.7 Regulated medical waste is cate-
gorized into the following seven classes:
• Class 1 — Cultures and stocks of infectious
agents, including among other things, specimen cul-
tures, culture dishes and inoculation devices, waste
production of biologicals, and discarded vaccines.
• Class 2 — Pathological wastes (tissues, organs,
and body parts).
• Class 3 — Human blood and blood products.
• Class 4 — Sharps used in animal or human pa-
tient care, e.g. needles, syringes, and broken or un-
broken glassware.
• Class 5 — Animal waste known to have been ex-
posed to infectious agents.
• Class 6 — Waste from special cases of humans
VOL. 87— NUMBER 2 FEBRUARY 1990
117
or animals isolated to protect others from certain
highly communicable diseases.
• Class 7 — Unused sharps.
Certain medical wastes are specially excluded or
exempted from the regulations. Examples of the
types of medical waste that NJDEP will not regulate
include: hazardous waste, waste generated as part
of home self-care, ash from incineration of regulated
medical waste, human body parts intended for
cremation or interment, and medical waste samples.
The regulations establish management standards
for regulated medical waste generators, transporters,
intermediate handlers (i.e. treatment or destruction
facility), and destination facilities. Again, the man-
agement scheme of the regulations is a cradle-to-
grave manifest system with each person having some
degree of responsibility in the process. Generally, the
requirements include logging, reporting, and mani-
festing. However, the standards do vary for the dif-
ferent persons in the management process. Further,
a person may be a generator, transporter, intermedi-
ate handler, and destination facility (or any vari-
ation thereof) at any one time, and, thus, should be
aware of the various regulatory obligations for each
status. For example, the regulations have a regis-
tration and fee requirement for generators, trans-
porters, intermediate handlers, and destination fa-
cilities. The fee calculation varies depending upon
status. A person that qualifies for more than one
status is required to register and submit individual
fees. NJDEP provides a graduated fee schedule for
medical waste generators. The schedule supposedly
is based on the annual waste generation rate. How-
ever, generators should be aware NJDEP proposes
to assess a base annual fee ranging from $528.50 to
$845.78. (MSNJ and other professional groups have
filed a suit contesting these charges.)
A generator’s management obligations can be
grouped into the following three categories: pre-
transport, tracking form, and recordkeeping. The
medical waste pretransport requirements consist of
segregation, packaging, storage, labeling, marking,
and transporter certification assessment. A gener-
ator does not have to comply with the pretransport
requirements if the regulated medical waste will be
disposed of on-site. First, a generator must segregate
waste into three groups prior to transport: sharps,
fluids, and all other regulated medical waste. Sec-
ond, the generator must place the waste in con-
tainers that are rigid, leak proof, impervious, tear or
burst resistant, and sealed. Third, if the generator
stores the packages prior to transport, then the
storage location should be protected from wind, rain,
and other water; locked to prevent access; protected
from insects or rodents; and refrigerated to prevent
decay, if necessary. Storage containers must be kept
free of visible contamination and any inner liners
must be handled as regulated medical waste.
Fourth, a generator must label each package as
medical or infectious waste or display the universal
biohazard symbol, unless the package contains
treated waste. Fifth, a generator must mark each
package with a tag containing generator specific in-
formation.8
A generator must ensure that the transporter
handling the regulated medical waste meets certain
registration requirements. Specifically, a generator
can use only those transporters that have NJDEP
registration numbers, have properly notified EPA,
and have a New Jersey Board of Public Utilities
certification. However, generators that transport
regulated medical waste for storage or disposal and
meet certain quantity, transportation vehicle, and
disposal restrictions, do not have to comply with
registration requirements.9
After the waste is packaged properly and prior to
transportation off-site, the generator must complete
a tracking form. Like the pretransport requirements,
a generator does not have to prepare a tracking form
for regulated medical waste that is treated, de-
stroyed, or disposed of on-site. Mechanical operation
of the tracking system varies depending upon the
mode of transportation and the class of waste trans-
ported. Typically, the generator must complete the
tracking form prepared by NJDEP. However, if the
regulated medical waste is transported out-of-state
and the disposal state participates in the EPA dem-
onstration program, then the generator must use the
tracking form of the disposal state. Failure to com-
plete the form properly is a violation of the regu-
lations which can result in enforcement action and
possibly, penalties.
The generator’s tracking obligations do not end
with completion of the form. Specifically, the gener-
ator is supposed to receive a completed tracking
form back from the destination facility within 35
days of when the waste was accepted by the trans-
porter. If the generator does not receive the com-
pleted tracking form within that time, then the gen-
erator must determine the status and location of the
waste.10 Specifically, the generator must contact the
transporter, intermediate handler, or disposal fa-
cility and identify the waste location. Assuming the
generator does not receive the completed tracking
form within 45 days of transport, the generator must
file an exception report with NJDEP and EPA."
A generator also has substantial recordkeeping re-
quirements. Typically, generators must keep copies
of tracking forms and must keep daily or monthly
logs, depending on waste generation rate (300
pounds per year or more — daily log; less than 300
pounds per year — monthly log).12 The regulations
have very specific technical requirements on the
contents of the logs. In addition, any generator that
118
NEW JERSEY MEDICINE
treats and destroys medical waste on-site must
maintain a record of those activities according to
NJDEP specifications. Finally, generators must sub-
mit an annual report of regulated medical waste
activity. NJDEP has the necessary forms.
Some generators operate on-site incinerators for
treatment and destruction of their medical waste.
Generators should be aware that on-site incinerators
expand their regulatory obligations with NJDEP. A
generator that incinerates its waste only must keep
a log of the incineration activity according to
NJDEP standards.13 If a generator also incinerates
regulated medical waste from off-site sources, then
the regulatory obligations are expanded signifi-
cantly. First, the generator must maintan an ex-
panded form of incineration log. Second, the gener-
ator becomes regulated as a destination facility.
With this status, the generator has additional track-
ing form obligations and recordkeeping require-
ments.14 Further, the generator has an obligation to
check the waste load, compare it with the data pre-
sented in the tracking form, and note any discrepan-
cies. If the generator notes discrepancies, then he
must report according to NJDEP standards.15
Any generator that operates an on-site medical
waste incinerator must have temporary NJDEP
authorization or comply with the engineering regis-
tration requirements applicable to all solid waste
incinerators. To obtain a temporary authorization,
the generator must first establish that the in-
cinerator was used to dispose of medical waste on
or before March 6, 1989, and that the incinerator
continues in operation. Also, the generator must
have a valid air pollution permit and pay the re-
quired registration fees. The regulations also require
compliance with operational standards for medical
waste incinerators before NJDEP will issue tempo-
rary authorization.16
CONCLUSION
The scope and effect of NJDEP’s medical waste
regulations are extraordinary. The typical physician,
dental, and veterinarian offices are subject to a full
panoply of environmental standards that require
diligence and effort to coordinate. NJDEP provides
few exceptions to the regulatory application and
eliminates the possibility of avoiding regulatory
compliance based on small quantity generator
status. Further, NJDEP would impose annual gener-
ator fees starting at a base range of $528.50 to
$845.78. The regulations create substantial oper-
ational burdens, economic concerns, and potential
penalties for a group never before subject to en-
vironmental standards. Medical practitioners now
must become fully cognizant of the final version of
the regulations and integrate a medical waste man-
agement system into their current operations. ■
Submitted: August 1989;
Accepted: September 1989
REFERENCES
1. New Jersey Administrative Code references for regu-
lation of health care facilities and their associated medical
waste management provision: residential alcoholism treat-
ment facilities (N.J.A.C. 8:31C-1.1 et seq., no medical
waste provision), long-term care facilities (N.J.A.C.
8:39-1.1. et seq.; specific medical waste provision,
N.J.A.C. 8:39-19.3), drug treatment facilities (N.J.A.C.
8:42B-1.1 et seq.; specific medical waste provision,
N.J.A.C. 8.-42B-19.2), ambulatory care facilities (N.J.A.C.
8:43A-1.1 et seq.; specific medical waste provision,
N.J.A.C. 8:43A-14.5), hospital facilities (N.J.A.C.
8:43B-1.1 et seq.; specific medical waste provision,
N.J.A.C. 8:43B-3.6).
2. N.J.A.C. 7:26-1.1 et seq.
3. N.J.A.C. 7:26-2. 13(g).
4. Public Law 100-582 (which amends 42 U.S.C. §6901
et seq.).
5. Public Law 1989, Chapter 34, N.J.S.A. 13:1E.48.1 et
seq.
6. 21 N.J.R. 2109, N.J.A.C. 7:26-3A-l.l et seq.
7. The definition of regulated medical waste appears at
7:26-3A,6 and states: “A regulated medical waste is any
solid waste, generated in the diagnosis, treatment (for
example, provision of medical services), or immunization
for human beings or animals, in research pertaining there-
to, or in the production or testing of biologicals that is
[listed in the regulations].”
8. Package marking requirements appear at N.J.A.C.
7:26-3A.15. Generally, a generator must mark each pack-
age with a water-resistant tag. This tag must include the
following information: 1. The generator’s or intermediate
handler’s name and address. 2. The transporter’s name,
NJDEP solid waste registration number, and date of ship-
ment. 3. Identification of contents as medical waste. The
requirement includes marking inner containers (i.e. within
the packaging) with indelible ink highlighting items 1 and
2 above.
9. N.J.A.C. 7:26-3A. 16(d).
10. N.J.A.C. 7:26-3A.22.
11. An exception report must be postmarked within 46
days of shipment of the medical waste off-site and include
the original tracking form, and a letter demonstrating
waste location investigative efforts. See N.J.A.C.
7:26-3A. 22(b)
12. N.J.A.C. 7:26-3A.21.
13. See N.J.A.C. 7:26-3A.25. The incineration log must
include (1) incineration start date, (2) incineration cycle
time (3) total waste quantity incinerated (with specific
estimate of medical waste composition), and (4) quantity
of ash generated.
14. A destination facility will receive a tracking form
from the transporter. The destination facility must sign
the tracking form, note discrepancies, give the transporter
a copy and send a copy to the generator. See N.J.A.C.
7:26-3A.39. The destination facility must keep a record of
all tracking forms (N.J.A.C. 7:26-3A.41) and submit an-
nual reports to NJDEP (N.J.A.C. 7:26-3A.42).
15. N.J.A.C. 7.-26-3A.40.
16. N.J.A.C. 7:26-3A.37.
VOL. 87— NUMBER 2 FEBRUARY 1990
119
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Cutaneous Malignant
Melanoma
JONATHAN O. NWILOH, MD
BARRY SUSSMAN, MD
ROSEMARY TAMBOURET, MD
HERBERT DARDIK, MD
From January 1973 to December 1985, 136 patients with primary cutaneous
malignant melanoma were treated at Englewood Hospital. Pathologic types,
methods of treatment, and results are discussed and a comparison of results
is made with other institutions.
Cutaneous malignant melanoma, once con-
sidered to be a rare malignancy with an un-
predictable biological behavior, now is
known to have the highest rate of increased in-
cidence of all cancers, except for bronchogenic
carcinoma.1 The biological behavior of these tumors
also is better understood by analysis of the various
histologic parameters identified to correlate closely
with survival. These parameters include Clark’s
level of invasion2 and Breslow’s tumor thickness.2
Although malignant melanoma is one of the skin
cancers frequently encountered in a community hos-
pital, most of the reports on melanoma have been
from university centers. We present the experience
in a community hospital for comparison of results.
PATIENTS AND METHODS
The records of 136 consecutive patients with
Drs. Nwiloh, Sussman, and Dardik are affiliated with the
Department of Surgery, Englewood Hospital. Dr. Tam-
bouret is affiliated with the Department of Pathology, St.
Vincent's Hospital and Medical Center, New York. Re-
quests for reprints may be addressed to Dr. Sussman,
Englewood Hospital, Englewood, NJ 07631.
cutaneous malignant melanoma (MM) treated at
Englewood Hospital between January 1, 1973, and
December 31, 1985, were reviewed. Englewood Hos-
pital is a 547-bed voluntary hospital located in
northern New Jersey. All patients, whether
diagnosed at Englewood Hospital or elsewhere, re-
ceived their treatment at Englewood Hospital.
During the study period, MM comprised 2 percent
of all cancers and 53 percent of all skin cancers seen
at this institution. Of these patients, 135 patients
(99 percent) were white and 1 patient (1 percent)
was black, with a sex distribution of 62 men (46
percent) and 74 women (54 percent). Ages ranged
from 21 to 91 years of age with a mean of 58.5 years;
maximum incidence was noted in the 50-to-59-year-
old age group. Also, 131 patients (96 percent) had
clinical stage I, 4 patients (3 percent) had stage II,
and 1 patient (1 percent) had stage III melanoma
on presentation. Also, 3 patients (2 percent), includ-
ing 1 patient with dysplastic nevus syndrome, had
a family history of MM.
The sites of distribution were trunk (38 percent),
lower extremities (29 percent), head and neck (19
percent), and upper extremities (14 percent) (Table
VOL. 87— NUMBER 2 FEBRUARY 1990
121
1). Also, 2 patients (1.5 percent) had multiple
primaries and 5 patients (4 percent) had satellite
lesions. Morphological types were superficial spread-
ing (SS) (42 percent); nodular (N) (15 percent); len-
tigo malignant (LM) (15 percent); acral lentiginous
(AL) (3 percent); and unclassified (25 percent).
Microstaging by Clark’s level of invasion revealed
level I to be 5 percent; level II to be 22 percent; level
III to be 29 percent; level IV to be 23 percent; level
V to be 7 percent; and unknown to be 14 percent.
Staging by Breslow’s tumor thickness revealed 139
thin (< 0.76 mm) melanomas (29 percent); 18 inter-
mediate (0.76 to 1.49 mm) melanomas (13 percent);
45 thick (> 1.5 mm) melanomas (33 percent); and
34 melanomas of unknown thickness (25 percent)
(Table 2). Ulceration was present in 24 patients (18
percent), absent in 72 patients (53 percent), and
unknown in 40 patients (29 percent).
Treatment for clinical stage I MM consisted of
wide local excision with a 3 to 5 cm margin. Head
and neck lesions had lesser margins because of cos-
metic considerations. Elective lymph node dissec-
tion (ELND) was performed in some patients with
high-risk lesions with levels III, IV, and V that were
equal to or greater than 0.76 mm in thickness. All
patients with clinical stage II MM underwent wide
local excision plus regional lymph node dissection.
Also, 12 patients underwent axillary dissections; 10
patients underwent superficial groin dissections; 1
patient underwent deep groin dissection; 3 patients
underwent modified neck dissections; and 2 patients
underwent radical neck dissections. Skin defects fol-
lowing wide excisions were closed primarily or with
skin grafts. Minor amputations were performed for
MM on the digits. Followup data by the tumor regis-
try were completed to December 1986. The mean
duration of followup was 4.7 years, with 9 patients
lost to followup. Survival rates were calculated by
life-table analysis. Disease-free survival was calcu-
lated from date of definitive surgery to date of first
documented local recurrence or metastatic disease.
Statistical significance was calculated by the chi-
square (X2) test.
RESULTS
Of our study group, 108 patients (79 percent)
underwent wide local excision (WLE); 9 patients (7
percent) underwent WLE plus ELND; and 19 pa-
tients (14 percent) underwent WLE plus deferred
lymph node dissection.
Following initial WLE, local recurrence developed
in 14 patients (10 percent) at a median time of 48
months. Subsequent metastases occurred in 19 pa-
tients (46 percent) with level IV to level V, compared
to 3 patients (4 percent) with level I to III ( P <
0.001). In addition, 19 patients (45 percent) with
thick melanomas equal to or greater than 1.5 mm
(mean +/- SD, 4.04 +/- 3.53, median 2.87 mm) de-
veloped metastases, compared to no metastases in
patients with thin or intermediate melanomas, less
than 1.5 mm thick (mean +/- SD, 0.61 +/- 0.36,
median 0.5 mm) (P < 0.001).
Of 9 patients in clinical stage I who underwent
ELND, 1 patient (11 percent) had occult metastases,
while 17 of 19 patients (90 percent) with clinically
positive lymph nodes undergoing delayed lymph
node dissection (DLND) had pathologically positive
nodes. Nine of 13 patients (69 percent) with lesions
equal to or greater than 4 mm thick later developed
distant metastases, compared to 8 of 29 patients (28
percent) with lesions between 1.5 to 3.99 mm in
thickness. In patients developing distant visceral
metastases, the most common sites of involvement
were lung (46 percent), liver (32 percent), brain (23
percent), and multiple sites (27 percent). Overall
five-year survival for clinical stage I patients was 86
percent, and five-year disease-free survival was 63
percent. Men had a poorer five-year survival rate of
Table 1. Site and growth pattern.
Site
Male %
Female
%
Total
%
Head and neck
24
15
19
Upper extremity
13
15
14
Lower extremity
16
39
29
Trunk
47
31
38
Type
Superficial spreading
43
41
42
Nodular
21
11
15
Lentigo malignant
15
16
15
Acral lentiginous
0
5
3
Unclassified
21
27
25
122
NEW JERSEY MEDICINE
VOL. 87— NUMBER 2 FEBRUARY 1990
123
71 percent as compared to women with a survival
rate of 83 percent. None of the patients with stage
II and stage III MM survived five years. The average
length of survival for the 4 patients with stage II
disease was 12.5 months and for the 1 patient with
stage III disease the length of survival was 1.5
months.
DISCUSSION
Malignant melanoma represented the most com-
mon cutaneous malignancy at our institution.
Although there are major melanoma treatment
centers across the nation (with established treat-
ment protocols), the surgeon in a community hospi-
tal frequently is faced with managing this disease.
Due to ongoing controversies in the literature regard-
ing management of regional lymph nodes, there
often is a dilemma in deciding when to perform
regional lymphadenectomy. This is reflected by the
lack of uniform criteria in selecting ELND versus
DLND among the surgeons at Englewood Hospital.
Despite these differences, a review of our patients
with MM shows comparable results with series from
larger centers in terms of prognostic variables and
survival.
Hereditary MM was noted in only three patients
Table 2.
Correlation of level (Clark)
and tumor thickness (Breslow) with
local recurrence,
metastases, and survival.
•
Level
No.
(%)
% Local
% Metastases
5 Yr.
Recurrence
Survival
1
7
(5)
—
—
—
II
30
(22)
3
—
100
III
39
(29)
8
8
85
IV
31
(23)
19
39
53
V
10
(7)
10
70
35
Unknown
19
(14)
11
47
—
Thickness
0.0-0.75
38
(29)
3
—
100
0.76-1.49
17
(13)
12
—
83
1.50-2.49
20
(16)
20
—
67
2.50-3.99
9
(7)
11
67
48
4.0
13
(10)
15
69
34
Unknown
32
(25)
16
38
—
Table 3.
Five-year survival.
Level
Wanebo et al.4
Eldh et al.5
Present Report
1
II
100
100
100
III
88
87
85
IV
65
72
53
V
16
35
35
Thickness
Balch et al.6
Present Report
0-0.75
89
100
0.76-1.49
75
83
1.50-2.49
58
67
2.50-3.99
46
48
> 4.00
35
34
124
NEW JERSEY MEDICINE
(2.2 percent), including one patient with a dysplastic
nevus. None of the patients with hereditary mela-
noma had multiple primaries, and these patients
had better survival than patients with sporadic MM.
Two patients with sporadic melanoma, representing
1.5 percent of the total, had multiple primaries. Men
had a poorer prognosis, possibly from having a
predominance of truncal lesions (47 percent) and
higher proportions of nodular growth pattern (21
percent), compared to women with a higher propor-
tion of lower extremity lesions (39 percent), and
lower proportion of nodular growth pattern (11 per-
cent).
Patient survival and the risk of regional lymph
node and distant metastases correlated very closely
with Clark’s level of invasion and Breslow’s tumor
thickness by an inverse proportion (Figures 1 and 2).
Our five-year survival of patients with level II (100
percent), level III (85 percent), level IV (53 percent),
and level V (35 percent) is similar to those reported
in the series of Wanebo et al.1 2 3 4 and Eldh et al.5 (Table
3).
Surgical extirpation of melanoma by wide local
excision, first proposed and performed by
Pemberton in 1858, 7 8 * remains the standard treatment
for clinical stage I MM. Present controversy sur-
rounds the benefits of ELND versus DLND. The
reported proportion of clinically negative, micro-
scopically positive regional lymph nodes range from
5 to 50 percent.89 Because patients with level II or
less than or equal to 0.76 mm MM have a very low
risk of regional node metastases, there is a consensus
that they do not require ELND. Most surgeons, how-
ever, would consider ELND in patients with level IV
to V and 1.5 to 3.99 mm lesions, because of the
higher risk of regional mode metastases, but rela-
tively low risk for distant metastases.1012 The rec-
ommended upper limit of 4 mm thickness for per-
forming ELND also is controversial. The proponents
of the 4 mm upper limit claim that the high risk for
distant microscopic metastatic disease in patients
with lesions equal to or greater than 4 mm, offsets
the benefits of ELND.6 Our experience supports this
view. Distant metastases occurred later in 9 of 13
patients (69 percent) with lesions equal to or greater
than 4 mm compared to 8 of 29 patients (28 percent)
with 1.5 to 3.99 mm lesions.
Overall, 28 patients (21 percent) in our series
underwent regional lymph node dissection. Nine pa-
tients (7 percent) had ELND, and 19 patients (14
percent) had DLND with five-year survivals of 67
percent and 53 percent, respectively. Because of the
small number of patients, no reliable statistical con-
clusion can be drawn from this data. The contro-
versy regarding the timing of regional lymphadenec-
tomy continues,13 reports of two trials of ELND by
Sim et al.14 and Veronesi et al.15 indicate that
survival rates are similar in patients with patho-
logically positive nodes, whether these are removed
during ELND or later, when clinically positive, by
DLND.
dismal, with limited palliation obtained from
chemotherapy, radiotherapy, immunotherapy, and
hormonal therapy. In this series from Englewood
Hospital, mean survival for stages II and III was 12.5
and 1.5 months, respectively. ■
Submitted: June 1989; Accepted: July 1989
REFERENCES
1. Kopf AW, Rigel DS, Friedman RJ: The rising in-
cidence and mortality rate of malignant melanoma. J
Dermatol Surg Oncol 8:760-761, 1982.
2. Clark WH, Jr, From L, Bernadino EA, Mihm MC:
The histogenesis and biological behaviour of primary
human malignant melanomas of the skin. Cancer Res
29:705, 1969.
3. Breslow A: Prognosis of cutaneous melanoma. Ann
Surg 172:902-908, 1970.
4. Wanebo HT, Woodruff A: Malignant melanoma of
the extremities: A clinicopathologic study using levels of
invasion (microstage). Cancer 35:666-676, 1975.
5. Eldh, TB, Peterson LE: Prognostic factors in
cutaneous malignant melanoma in stage I: A clinical
morphological and multivariate analysis. Scand T Plast
Reconst Surg 12:243-255, 1978.
6. Balch CM, Soong ST, Milton GW, et al.: A com-
parison of prognostic factors and surgical results in 1,786
patients with localized (stage I) melanoma treated in Ala-
bama, USA, and New South Wales, Australia. Ann Surg
196:677-683, 1982.
7. Urteaga OB, Pack GT: On the antiquity of mela-
noma. Cancer 19:607-610, 1966.
8. Sim FH, Taylor WF, Ivias JC, et al.: A prospective
randomized study of the efficacy of routine elective
lymphadenectomy in management of malignant mela-
noma. Cancer 41:948-956, 1978.
9. Roses DF, Harris MN, Hidalgo D, et al.: Primary
melanoma thickness correlated with regional lymph node
metastases. Arch Surg 117:921-923, 1982.
10. Clark WH: A classification of malignant melanoma
in man correlated with histogenesis and biological behav-
iour, in Montagna BW, HuF (eds), Advances in Biology
of Skin. New York, NY, Pergamon Press, 1967.
11. Hansen MG, McCarter AB: Tumor thickness and
lymphocytic infiltration in malignant melanoma of the
head and neck. Am ■ J Surg 128:557-561, 1974.
12. Wanebo HJ, Fortner JG, Woodruff T, et al.: Selec-
tion of the optimal surgical treatment of stage I melanoma
by depth of microinvasion: Use of combined microstage
technique (Clark-Breslow). Ann Surg 182:302-313, 1975.
13. Symposium: Controversies in the treatment of ma-
lignant melanoma. Contemp Surg 32:99-121, 1988.
14. Sim FH, Taylor WF, Pritchard I, et al.:
Lymphadenectomy in the management of stage I malig-
nant melanoma: A prospective randomized study. Mayo
Clinic Proc 61:697-705, 1986.
15. Veronesi U, Adamus T, Bandiera DC, et al.: De-
layed regional lymph node dissection in stage I melanoma
of the extremities. Cancer 49:2420-2430, 1982.
VOL. 87— NUMBER 2 FEBRUARY 1990
125
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126
NEW JERSEY MEDICINE
Pasteurella Multocida
Meningitis
OMAR COSTA-CRUZ, MD
ANNA MARIE SESSO, MD, MPH
SHRIKRISHNA MATE, MD
ELLIOT FRANK, MD
The diagnosis of Pasteurella multocida meningitis was confused by a false-
positive latex particle agglutination test implicating group B streptococcus.
This illness and false-positive reactions in antigen detection are discussed.
Pasteurella multocida, a small gram-negative
coccobacillus that commonly colonizes the
respiratory tract of birds and mammals
(particularly cats and dogs), has long been known
to cause infection in man following a bite or
scratch.1'3
Although rare, severe infection without prior
trauma does occur. Both sepsis and meningitis have
been documented in infants who have had non-
traumatic mucous membrane contact with a pet dog
or cat.12'6'7
We present a case in which an infant developed
P. multocida meningitis through mucous membrane
contact with the family’s dog. This case is of particu-
lar interest because the dog was encouraged to lick
the infant’s face and mouth in the interest of bond-
ing, and because the initial etiologic diagnosis was
confounded by a false-positive latex particle ag-
glutination (LPA) test suggesting group B strep-
tococcal infection.
Drs. Sesso, Mate, and Frank are affiliated with the De-
partments of Pediatrics and Medicine, Jersey Shore
Medical Center. Dr. Costa-Cruz is a fellow in neonatology
at St. Peter’s Medical Center, New Brunswick. The
authors thank Clarence Manziano, DVM, for his as-
sistance with information concerning animal-young child
bonding. Requests for reprints may be addressed to Dr.
Sesso, Jersey Shore Medical Center, 1945 Route 33,
Neptune, NJ 07754.
CASE REPORT
An eight-week-old white infant male, treated for
otitis media at four weeks of age, appeared irritable.
His pediatrician found no abnormality nor focus of
infection. The patient developed a temperature of
39.9°C, and was admitted to the hospital.
The infant was born at term by spontaneous va-
ginal delivery. Apgar scores were 9 at one and five
minutes. The baby had been adopted at 48 hours of
age, and no other history was available.
On admission, the physical examination revealed
an infant whose skin was hot, dry, and flushed. His
fontanel was soft but slightly bulging. The tempera-
ture was 39.1°C, and the apical pulse was 156/min.
He weighed 5.8 kg. The examination was otherwise
unremarkable. The white blood count was 11,100/
mm3 with 86 percent polymorphonuclear leukocytes,
37 percent lymphocytes, and 8 percent band forms.
A cerebrospinal fluid (CSF) examination revealed
1,566 WBC/mm' of which 99 percent were poly-
morphonuclear cells. The CSF glucose was 49 mg/dl
and the protein was 103 mg/dl. No organisms were
seen on a gram-stained smear of the CSF but the
latex particle agglutination (LPA) test was positive
for group B streptococcal antigen. Blood, throat, and
urine cultures were obtained. Intravenous ampicillin
(Omnipen-N®) 300 mg/kg/day, gentamicin (Gara-
mycin®) 7.5 mg/kg/day, and ceftriaxone (Rocephin®)
100 mg/kg/day were initiated. The infant was trans-
VOL. 87— NUMBER 2 FEBRUARY 1990
127
ferred to the pediatric intensive care unit (PICU) at
Jersey Shore Medical Center for further care.
On arrival in the PICU, the patient was extremely
irritable but alert. The physical examination was
otherwise normal. The vital signs were: temperature
32.8°C, pulse 140/min, respirations 39/min, and a
blood pressure of 96/58 mm Hg. He weighed 5.8 kg.
The complete blood count was: hemoglobin 8.8 g/dl,
hematocrit 26.7 percent, WBC 11,600 per mm3 with
14 percent polymorphonuclear cells, 16 percent
bands, 60 percent lymphocytes, and 10 percent
monocytes. The platelet count, urinalysis, serum
electrolytes, urea nitrogen, and creatinine were nor-
mal. A chest roentgenogram showed mild pulmonary
hyperaeration. Blood, urine, throat, and rectal cul-
tures were repeated. Antigen detection on a boiled
sample of the original CSF was repeated by LPA and
again was positive for group B streptococcus. No
agglutination was observed using reagents for
Neisseria meningitidis, Haemophilus influenzae,
Streptococcus pneumoniae, or control reagents.
All cultures remained negative for 48 hours. On
the third day, the referring hospital isolated P.
multocida from the CSF on sheep blood and choc-
olate agar which then was confirmed.
Blood, urine, and throat cultures done at both
hospitals remained negative.
In light of the identification of P. multocida,
further history was elicited from the parents which
revealed a pet dog was being bonded to the baby by
encouraging it to lick the baby’s face and mouth. A
culture obtained by a veterinarian from the dog’s
oropharynx grew P. multocida.
The infant remained febrile to 39.4°C until after
the third day of antibiotic therapy. On hospital day
five, gentamicin was discontinued and ampicillin
300 mg/kg/day was continued to complete ten days
of therapy. A lumbar puncture done 24 hours after
the cessation of antibiotic therapy revealed sterile
cerebrospinal fluid with 5 WBC/mm' (one poly-
morphonuclear cell, four lymphocytes), 520
RBC/mm1, protein 54 mg/dl, and glucose 34 mg/dl.
LPA was negative with all reagents. The infant’s
recovery was uneventful and he was returned to the
care of his private pediatrician.
DISCUSSION
The frequent contact of the dog’s saliva with the
infant’s oral mucosa in addition to the isolation of
Pasteurella multocida from both the dog’s saliva and
the child’s spinal fluid make it likely that the trans-
mission of the organism through the mucous mem-
branes occurred. This has been described in the
literature. 1,2,8
A confusing aspect in this case was that on two
different occasions, in two different laboratories, the
LPA was positive for group B streptococcus. All anti-
gen detection methods have the potential for false-
positive reactions.912 With LPA, these reactions may
reflect nonspecific agglutination or true cross-reac-
tivity between antigen components of different
bacteria. Nonspecific agglutination is suggested
where there is agglutination of control latex beads.12
Such reactions may be due to heat labile factors and
can be minimized by boiling specimens prior to test-
ing.9 Nonspecific false-positive reactions due to
circulating IgM antibodies can be counteracted by
the addition of dithiothreitol to the specimen.11
Since nonspecific agglutinins generally are present
in low titers, dilution of serum also will reduce con-
fusion in most cases.9
Specific false-positive reactions have been de-
scribed with all antigen detection techniques but are
very unusual.10 Cross-reactions between different
subtypes within a species and, to a lesser extent,
between different species within a genus usually will
not pose a clinical risk. Intergeneric cross-reaction,
such as we observed in this case, could have very
significant consequences and fortunately are rare.
Using countercurrent immunoelectrophoresis, anti-
sera against Haemophilus influenzae antigen have
been shown to cross-react with strains of Escherichia
coli, Streptococcus pneumoniae, and Staphylococ-
cus aureus. Antisera against 5. pneumoniae have
been shown to cross-react with strains of Neisseria
meningitidis and alphastreptococci; and the anti-
sera against N. meningitidis have been shown to
cross-react with strains of E. coli and H. para-
inf luenzae P
False-positives also have been uncommon with
LPA, where reagents for H. influenzae have reacted
in patients with meningococcemia and E. coli
bacteremia.10,13 LPA to detect group B streptococcal
antigen has cross-reacted with group G streptococcal
antigen and S. aureus, but has not been reported to
cross-react with Haemophilus sp., Neisseria sp., or
other gram-negative organisms.14 The basis for the
cross-reaction in our patient is unclear but a
nonspecific reaction seems unlikely since no ag-
glutination was observed with control latex beads.12
The etiologic diagnosis of meningitis is made by
the isolation of the offending organism from CSF.3
In this case, Pasteurella multocida typically grew on
sheep blood and chocolate agar but not on Mac-
Conkey’s media.1,2,8 Morphologically, Pasteurella
multocida is similar to other central nervous system
pathogens such as Haemophilus influenzae and
Neisseria meningitidis, but modern laboratory tech-
niques facilitate its identification.1,2
Penicillin and ampicillin consistently have been
effective against Pasteurella multocida both in vitro
and in vivo. Because these agents penetrate the cen-
tral nervous system, they remain the drugs of choice
for all infections caused by P. multocida including
128
NEW JERSEY MEDICINE
meningitis. In addition, this organism is susceptible
to numerous other antibiotics including the ex-
tended spectrum penicillins, cephalosporins, tetra-
cyclines, fluoroquinilones, and chloramphenicol
(Chloromycetin®). However, while Pasteurella
multocida is exquisitely sensitive to the newer
cephalosporins such as cefuroxime (Ceftin®),
cefotaxime (ClaforarD), ceftizoxime (Cefizox®), and
ceftriaxone, the activity of older drugs in this class
such as cephalexin (Keflex®) and cefadroxil
(Duricef®) may be unreliable, especially in concen-
trations achievable with oral administration. Simi-
larly, some strains of P. multocida are resistant to
the antistaphylococcal penicillins, nafcillin (Uni-
pen®), and dicloxacillin (Dynapen"), and most or all
strains are resistant to clindamycin (Cleocin®) and
vancomycin (Vancocin®).35
In this case, ampicillin and gentamicin were
initiated prior to the isolation of the organism as the
usual empiric regimen for meningitis in this age
group. When the organism and its sensitivity to am-
picillin were confirmed, that antibiotic was used ex-
clusively. Several reported cases were treated simi-
larly with good results. I'2 3 4 5 6 7'7,8
Several deaths have been reported after systemic
infection with Pasteurella multocida. In infants who
have been treated with appropriate antibiotic ther-
apy, the outcome generally has been good and only
a few have had neurological sequelae.18 The infant
in this case did not exhibit any immediate neuro-
logical problem and one year after discharge from
the hospital, both his physical and neurological
examinations were normal and he had achieved all
the expected developmental milestones for his age.
It is common for families to have close contact
with and affection for household pets, particularly
cats and dogs. When there is a newborn, part of the
adaptation period may include attempting to bond
the infant to the animal. This may include per-
mitting the animal to lick or nuzzle the child.
At least one-half of the documented cases of
Pasteurella multocida meningitis and sepsis have
occurred in infants under one year of age. Like our
patient, many of these children did not sustain any
injury from the animal.167'8
Since infants seem to be at increased risk of
mucosal invasion by this organism, the physician
should attempt to prevent this infection by obtain-
ing a history related to household pets at the time
of instruction in newborn care. The parents should
be advised about thorough handwashing between
handling of the pet and the child, and they should
be cautioned of the risk to the child by direct contact
with the pet. (Other zoonotic infections may be
avoided in this way as well.)
Attempts at bonding should be delayed until the
child is crawling and can recognize the animal as
“something.” At this time, the child may pet or
stroke the animal if the animal is amenable to such
attention. The parent should assess the tempera-
ment of the animal. Some do not favor children and,
thus, cannot be bonded. An adult must be present
and close to the animal and child at all times. ■
Submitted: August 198S,
Accepted: September 1989
REFERENCES
1. Clapp DW, Kleinman MB, et al . : Pasteurella
multocida meningitis in infancy. An avoidable infection.
Am J Dis Child 140:444-446, 1986.
2. Thompson CM, Pappu L, Leukoff AN, et al.:
Neonatal septicemia and meningitis due to Pasteurella
multocida. Pediatr Infect Dis 3:595-561, 1984.
3. Stechenberg BW, et al.: Pasteurella multocida infec-
tion, in Feigin RD, Cherry JD (eds): Textbook of Pediatric
Infectious Disease. 2nd Edition. Philadelphia, PA, WB
Saunders, 1987, pp 1224-1227.
4. Shikuma CC, Overturf GD: Antibiotic susceptibility
of Pasteurella multocida. Eur J Clin Microbiol 4:518-519,
1988.
5. Goldstein EJC: Comparative activities of cefurox-
ime, amoxicillin-clavulanic acid, ciprofloxacin, enoxacin,
and ofloxacin against aerobic and anaerobic bacteria
isolated from bite wounds. Antimicrob Agents Chemother
32:1143-1148, 1988.
6. Repice JP, Neter E: Pasteurella multocida men-
ingitis in an infant with recovery. J Pediatr 86:91-93, 1975.
7. Frutos AA, Levinsky D, Scott EG, et al.: A case of
septicemia and meningitis in an infant due to Pasteurella
multocida. J Pediatr 92:853, 1978.
8. Weber DJ, Wolfson JS, Swartz MN, et al.:
Pasteurella multocida infections: Report of 34 cases and
review of the literature. Medicine 63:133-154, 1983.
9. Wilson CB, Smith AL: Rapid tests for the diagnosis
of bacterial meningitis, in Remington JS, Swartz MN
(eds): Current Clinical Topics in Infectious Diseases. New
York, NY, McGraw-Hill, 1986, pp 134-156.
10. Kaplan SL: Antigen detection in cerebrospinal
fluid — pros and cons, in Balows A, Tilton RC (eds): Body
Fluids and Infectious Diseases. Am J Med, 1983.
11. Bromberger PI, Chandler B, Green H, Haddow JE:
Rapid detection of neonatal group B streptococcal infec-
tions by latex agglutinations. J Pediatr 96:104-106, 1980.
12. Baker CJ, Rench MA: Commercial latex agglutina-
tion for detection of group B streptococcal antigen in body
fluids. J Pediatr 102:393-395, 1983.
13. Daum RS, Siber GR, Kamon JS, Russell RR:
Evaluation of a commercial latex particle agglutination
test for rapid diagnosis of Haemophilus influenzae type B
infection. Pediatrics 69:446-471, 1982.
14. Friedman CA, Wender DF, Rawson JE: Rapid
diagnosis of group B streptococcal infection utilizing a
commercially available latex agglutination assay. Pedi-
atrics 73:27-30, 1984.
15. Stevens DL, Higbee JW, Oberhofer TR, Everett
ED: Antibiotic susceptibilities of human isolates of
Pasteurella multocida. Antimicrob Agents Chemother
16:322-324, 1970.
VOL. 87— NUMBER 2 FEBRUARY 1990
129
Your own
ippilirinp
The Exchange is the only company
providing professional liability insurance that is
endorsed and sponsored by the Medical Society
of New Jersey.
The Exchange was founded in 1976 by the
Society itself because New Jersey physicians
urgently needed a secure, stable professional
liability program. The commercial carriers had
abandoned the State. The Exchange is
governed by its insured physicians because a
doctor-owned company can best take care of
medical professionals’ needs.
That’s why the Exchange’s membership
includes more than 7,500 practicing physicians
and surgeons in New Jersey . . . a taste of their
own medicine.
130
NEW JERSEY MEDICINE
NOTEBOOK
■ TRUSTEES’ REPORT ■
A regular meeting of the Board
of Trustees was held on December
17, 1989, at the Executive Offices.
Detailed minutes are on file with
the secretary of your county so-
ciety. A summary of significant ac-
tions follows:
Report of the President . . .
(1) Update . . . Noted Dr.
Hirsch’s comments on special
dates for meetings and on the
Medical Books for China Inter-
national Foundation Project.
(2) JEMPAC . . . Stated the final
report of the Nominating Commit-
tee is expected to be ready for the
January 1990 meeting; Dr. Hirsch
reiterated his hope that all Board
members will join JEMPAC; and
Dr. Ryan stated he will continue
his efforts for JEMPAC as an ex-
officio member.
(3) Executive Committee Meet-
ing . . . Reviewed the following:
Dr. Mineur noted approval of a
$50,000 dividend from the Medical
Underwriters to MSNJ and that
MIIENJ will continue its policy of
providing grants to MSNJ for cer-
tain activities.
(4) Task Force on AIDS . . .
Noted that a letter was sent to
James Florio requesting the estab-
lishment of an interagency task
force to include strong represen-
tation from MSNJ.
AMA Interim Meeting . . . De-
scribed the following items: a din-
ner honoring Drs. William J.
D’Elia and Myles C. Morrison, Jr,
retiring as members of the AMA
Delegation; and Dr. Palma For-
mica’s candidacy for the AMA
Board of Trustees.
AMA Interim Meeting Reports:
Noted the following actions by the
Board of Trustees concerning the
following: Report QQ (Strengthen-
ing the AMA: Fiscal Responsibility
and Oversight) — an independent
investigation will be conducted, no
financial arrangements are to be
made with any employees by the
executive vice-president, Dr. Sam-
mons will retire on March 31, 1991,
and the Board will formulate and
institute specifically defined limits
upon the authority of the executive
vice-president in respect to mone-
tary, compensation, and health
policy matters to conform to the
exercise of the Board’s fiduciary
responsibilities; Report CC (Ma-
ternal/Fetal Conflict) — deter-
mined to be outdated and will be
discussed at the June meeting; Re-
port Z (Constitutional Challenges
to MAACs as an Interference with
the Right To Contract) — MAAC
will be approached legislatively;
and Resolution 42 (Public Educa-
tion about Medical Costs) — adopt-
ed the following:
Resolved, that the AMA carry out a
factually based public education cam-
paign clearly delineating the elements
of medical care expenditures and ex-
plaining the factors leading to unwar-
ranted, unavoidable, or unproductive
expenses which are not subject to phy-
sician control: unhealthy lifestyles, an
aging population, high health in-
surance administrative costs, inap-
propriate applications of technology,
and support of unneeded hospital
beds.
and 1989 figures are attributable to
the special assessment and the
CME requirement.
(2) Financial Statements . . . Re-
viewed and approved the final
statements for November 1989.
(3) Federal Budget Reconcili-
ation . . . Stated that an un-
abridged version of the report is
available upon request.
(4) Legislation . . . Noted the fol-
lowing: S-2936 (Medical Licensing
Reform) is pending final passage in
the Assembly, then it will go to the
Senate, and the governor; and con-
cerning the medical waste regis-
tration fee schedule, most physi-
cians would pay $100 annually.
(5) Litigation . . . Discussed liti-
gation on the malpractice sur-
charge; PRO versus MSNJ; MSNJ
versus the State Board of Physical
Therapy; and PRO versus Diaz
(sanctioned by PRO for a violation
at Salem Hospital).
(6) Physicians’ Health Program
Offices . . . Authorized construc-
tion of the office suite for the Phy-
sicians’ Health Program due to
program growth.
(7) CME . . . Stated that MSNJ
has been notified of continued rec-
ognition for two years by the Com-
mittee on Review and Recognition
of the ACCME.
(8) Referring Physician Iden-
tifier Numbers (Medicare) . . .
Noted that physicians should
check listings in the Pennsylvania
Blue Shield booklet for accuracy.
Special Reports . . . Received re-
Report of Executive Director . . . ports from the University of Medi-
(1) MSNJ Paid Membership . . . cine and Dentistry; the New Jersey
Noted that as of November 1989, Hospital Association, and the
total paid membership was 7,416; Academy of Medicine of New Jer-
the difference between the 1988 sey.
VOL. 87— NUMBER 2 FEBRUARY 1990
131
Committee on Utilization Review
Systems . . .
(1) Physician Attestation . . .
Approved the following recommen-
dations from the Committee, with
editorial changes (noted in italics):
That the attestation clause be printed
on, or attached to, the bottom of the
face sheet of the patient’s chart (rather
than having a separate computer-gen-
erated face sheet) so that, the physician
attests only to that which he himself
has written.
That physicians be informed by the
Medical Society of New Jersey that
when signing an attestation form, they
are attesting to the best of their knowl-
edge that the diagnoses and procedures
shown on the patient’s chart are ac-
curate.
(2) AXIOM REVIEW Quality
Assurance Plan . . . Approved the
following:
That the Medical Society of New Jer-
sey Executive Committee contact the
Commissioner of Health and request
that all state-certified utilization re-
view organizations have appropriate
due process in their written quality as-
surance plans.
Senior Citizens Task Force . .
Approved the following recommen-
dation from the Task Force:
That the problems of senior citizens as
discussed by the Senior Citizens Task
Force be communicated to the mem-
bership in a form and frequency to be
determined subsequently.
Committee on Biomedical Ethics
. . . Approved cosponsorship of the
seminar, noting that it will not in-
volve any financial expenditure on
the part of the Medical Society of
New Jersey:
That MSNJ cosponsor the Citizens’
Committee on Biomedical Ethics, Inc.,
seminar entitled, “In the Patient’s
Best Interest — Partners in the Con-
tinuum of Caring,” scheduled to be
held on January 31, 1990, at Princeton
University.
New Business . . . Voted to
donate $1,000 gift to the Phy-
sicians’, Health Program of the
Medical Society of New Jersey.
^UMDNJ NOTFSM
A daily dose of the drug deprenyl
can delay significantly the progress
of Parkinson’s disease. This im-
portant discovery was announced
by investigators at UMDNJ-Rob-
ert Wood Johnson Medical School
and Robert Wood Johnson Univer-
sity Hospital. They were among 28
nationwide centers participating in
a federally funded study.
Started in 1985, the study of 800
patients with early Parkinson’s
disease revealed that a daily dose
of 10 mg of deprenyl significantly
delayed the onset of the more
serious signs of the disease.
The protective effect of deprenyl
is the second anti-Parkinson use of
this drug tested at the New Bruns-
wick-based medical school. Based
on UMDNJ studies, we know the
drug can lessen some of the motor
fluctuations encountered in the
middle and advanced stages of the
disease. This previous research was
the basis for the Food and Drug
Administration’s approval to pre-
scribe deprenyl for advanced cases.
The latest study, called
DATATOP (Deprenyl and
Tocopherol Anti-Oxidative Ther-
apy of Parkinsonism), is a clinical
trial of the Parkinson study group,
sponsored primarily by the Na-
tional Institute of Neurological
Disorders and Stroke of the Na-
tional Institutes of Health. The
study group, comprising 28 United
States and Canadian universities
and hospitals, is designed to test
the effects of deprenyl and
tocopherol, a form of vitamin E, on
patients with early symptoms of
Parkinson’s disease. The benefits
of tocopherol have yet to be
assessed.
A new Ozone Research Center
has been started at the Piscat-
away-based Environmental and
Occupational Health Sciences In-
stitute (EOHSI), operated by
UMDNJ and Rutgers University.
The Center will be the focal point
for major ozone-related research in
New Jersey and the Northeast. It
will pursue basic and applied re-
search on such ozone issues as the
chemical formation and destruc-
tion of ozone, atmospheric trans-
port of ozone and its precursors,
and human exposure to ozone.
The Center has been established
through a five-year, $450,000 grant
from the New Jersey Department
of Environmental Protection and
will be headed by Dr. Paul J. Lioy,
director of EOHSI’s Exposure
Measurement and Assessment
Division and professor of en-
vironmental and community medi-
cine at UMDNJ-Robert Wood
Johnson Medical School.
UMDNJ broke ground last
month for a new, reduced-cost
child care center to serve students,
faculty and staff. It is expected to
be the flagship for similar services
at each of the University’s three
campuses. In Newark, a free-
standing child care center will be
erected on land leased from the
University. Being built and man-
aged by Kinder-Care Learning
Centers, the nation’s largest
proprietary child care provider, the
facility is scheduled to open in
March.
Michael S. Katz, UMDNJ’s di-
rector of student financial aid, has
been appointed to the National
Advisory Committee on Student
Financial Assistance. Mr. Katz,
who has directed student finanical
aid at UMDNJ for ten years, serves
on the Association of American
Medical College’s Committee on
Student Financial Assistance and
its subcommittee on Student Loan
Default . He also is a member of the
Department of Higher Education’s
Loan Advisory Committee and its
Martin Luther King Physician/
Dentist Scholarship Program. □
Stanley S. Bergen, Jr, MD
■H MSNJ ASSESSMENT ■
According to a directive from the
Board of Trustees of the MSNJ,
the following is a list of Society
members who have not paid the
special assessment:
132
NEW JERSEY MEDICINE
Bergen County
Antler, Arthur S, MD
Apovian, John, MD
Banschick, Harry, MD
Barrett, Joan, MD
Behnam, Kazem K, MD
Berrin, Victoria L, MD
Bufalo, Joanna, MD
Carluccio, Charles Goldhammer, MD
Chenen, Stephen H, MD
Cuddihy, Kathleen Virginia, MD
De Luca, Vincent A, MD
De Mauro, Peter J, MD
De Mayo, Joseph M, MD
Epstein, Menachem Yakov, MD
Glassman, Ronald, MD
Gonzales, Optaciano Chipeco, MD
Grosso, Joseph, MD
Harris, Robert M, MD
Heldman, Jay P, MD
Kozam, Robert Leslie, MD
Lanza, Frank J, MD
Levy, Albert, MD
Massarelli, Lucian George, MD
Natoli, Dennis T, MD
Palad-Doiranlis, Zenaida, MD
Paltrowitz, Irving M, MD
Parian, Joseph M, MD
Penny, John L, MD
Ravits, Margaret, MD
Rosenberg, Seligman, MD
Sethi, Virender, MD
Siegel, Jerald, MD
Slater, John G, MD
Sofianides, Thomas, MD
Spierenburg-Remmerde, Ruth, MD
Sung, Ui Joon, MD
Terrin, Bruce N, MD
Valdes, Aurelio, MD
Walsh, Patrick M, MD
Wang, Kyu Sung, MD
Weinstock, Murray, MD
Burlington County
Addis, David J, MD
Brill, Robert F, MD
Cohen, Douglas Jay, MD
Cynn, Jhin Jha, MD
Evans, II, Nathaniel R, MD
Fish, Frank H, MD
Grossman, Leonard, MD
Hanasoge, Lakshmi A, MD
Koss, James C, MD
LaManna, Margaret, MD
Levine, Richard T, MD
Lynch, Roberta M, MD
Meltsner, Gilbert, MD
Miller, William B, DO
Puttaswamy, Dunthur M, MD
Ryan, Kathleen, MD
Tangco, Evacueto P, MD
Topiel, Martin S, MD
Zagerman, Abraham J, MD
Camden County
Addiego, Frank J, MD
Armstrong, James S, MD
Aseron, Reynaldo A, MD
Blum, Stuart F, MD
Brennan, Jr, Charles LS, MD
Cajulis, Arthur B, MD
Cypel, David, MD
Enriquez, Carlos A, MD
Fisher, Thomas F, MD
Friedman, Harold S, MD
Gillerlain, Joseph Anthony, MD
Glass, Harvey, MD
Hong, Robert S, MD
Liberi, Ercole Joseph, MD
Me Clure, A. Gregory, MD
Meredith, J. Rodney, MD
Moheimani, Hessam, MD
Rosenberg, Anne L, MD
Santos, Rodrigo R, MD
Siemons, Gary 0, MD
Tama, Albert R, MD
Trunzo, Thomas Harold, MD
Wiener, Leslie, MD
Cumberland County
Chmelewski, Anthony Edward, MD
Huston, Jr, Donald C, DO
Mazer, Howard, MD
Pavlin, Walter, MD
Read, John H, MD
Stewart, Robert M, MD
Torres-Zayas, Francisco J, MD
Essex County
Aduna-Yap, Norma S, MD
Asaadi, Mokhtar, MD
Ashendorf, Douglas, MD
Atehortua, Diego, MD
Atherley, Trevor H, MD
Bell, Alvin, MD
Brown, Thomas F, MD
Cabrera, Lilia Ventura, MD
Caprio, Anthony AF, MD
Chang, Ya-Horng, MD
Charles, Seymour, MD
Cho, Dong W, MD
Clemente, Celestino, MD
Compagnone, Franco, MD
Cooney, Mary E, MD
De Guzman, Daisy, MD
De La Cruz, Jr, Catalino L, MD
Decter, Edward M, MD
Di Giacomo, William A, MD
Di Gregorio, Frank, MD
Dix, Jacquelyn E, MD
Fan, Foun-Chung, MD
Fein, Eric N, MD
Flora, Alphonse Ronald, MD
Frankel, Howard Jonathan, MD
Goldfarb, Irvin D, MD
Griffith, William H, MD
Hanauer, Lonnie B, MD
Harris, Michael, MD
Iqbal, Shamin, MD
Jain, Sudesh S, MD
Jerez, Cesar Julio, MD
Karetzky, Monroe S, MD
Keller, M. Mahboubi, MD
Kelly, Jr, Leo, MD
Kim, Kun, MD
Kirschner, Marvin A, MD
Krawczuk, Roman J, MD
Lagman-Lising, Librada N, MD
Miller, Philip M, MD
Modi, Mahendra R, MD
Modny, Cynthia J, MD
Napuli, Maximo C, MD
Nicoll, Anca M, MD
Oana, Dan C, MD
Orleans, Julian, MD
Park, Yong Moo, MD
Patel, Chandrakant, MD
Pecora, AM, MD
Pitoscia, Thomas, MD
Prasad, Sheo Shanker, MD
Rios, Jose, MD
Rizvi, Masood A, MD
Samady, Abdul R, MD
Samson, Cesar R, MD
Savino, Leonard, MD
Scoppetuolo, Michael H, MD
Segen, Joseph, MD
Sesta, Hee-Ja, MD
Sheng, Kung Tso, MD
Solomon, Normand Norris, MD
Strauss, Bernard S, MD
Suwanee, Sue, MD
Thomas, Alapatt P, MD
Tolentino, Eduardo D, MD
Wurzel, Bernard S, MD
Wychulis, Adam R, MD
Yap, Agustin U, MD
Gloucester County
Buxbaum, Howard H, MD
Hudson County
Arias, Arturo A, MD
Baker (Abubaker), Azzam A, MD
Bankier, Mark, MD
Behin, Fereidoon, MD
Blank, Ellen, MD
Calizo, Ulderico E, MD
Cherne, Vadim, MD
Corteza-Malantic, Vivina, MD
De Angelis, Silvio, MD
Gadhok, Kanwaljit, K, MD
Hashemiyoon, Ahmad, MD
Iyengar, Devarajan, MD
Mahan, Kenneth Wells, MD
Mark, David Nuen Yuk, MD
VOL. 87— NUMBER 2 FEBRUARY 1990
133
Masson, Lalitha, MD
Medrano, Eduardo V, MD
Perez-Mendez, Jesus, MD
Prakash, Anaka KR, MD
Salomon, Hubert, MD
Serafino, Vincent, MD
Soberano, Alfonso J, MD
Sowa-Wandycz, Ewa Barbara, MD
Hunterdon County
Doyle, Louis Philip, MD
Goger, Pauline Rohm, MD
Huttner, Ruby P, MD
Quinn, Brian M, MD
Mercer County
Bada, Jr, Laureto S, MD
Battin, Keith Gierhart, MD
Brown, William Charles, MD
Buzard, Thomas A, MD
Chaudry, Mohammad Hanif, MD
Christie, Alfred Douglas, MD
De Blasio, Joseph M, MD
De Goma, Rolando L, MD
Di Biase, John J, MD
Faraoniw, Bohdan, MD
Fraser, Leon, MD
German, Elaine U, MD
Gilfillan, Richard J, MD
Gupta, Vinod K, MD
Hagaman, John F, MD
Hoyos, Fernando, MD
Hutchison, Dwight C, MD
Jaferi, Ghazanfar A, MD
Kent, David W, MD
Kososky, Charles S, MD
Laurente, Romeo V, MD
Laurente, Cristeta A, MD
Lien, Hosanna W, MD
McCabe, Jonathan, MD
Saltstein, Elliott S, MD
Talwani, Muhammad Y, MD
Thirugnanam, Saraswathi, MD
Tsai, Thomas C, MD
Victor, Carl H, MD
Williams, Paul T, MD
Middlesex County
Babiak, Eugenia T, MD
Brody, Herbert Stephen, MD
Cho, Seung C, MD
Choi, Stanley SW, MD
Cioffi, Francis J, MD
De Guzman, Jaime L, MD
Dugenio, Jose E, MD
Fabbro, Leo A, MD
Feldman, Mark A, MD
Fernandez, Manuel A, MD
Galli, Thomas George, MD
Gandhi, Hans R, MD
Karu, Moiz S, MD
Lenger, Ellis S, MD
Lenz, Paul R, MD
Lin, Pei-Zin, MD
Lo, Jiun H, MD
Maing, Basil Sungyoul, MD
Mannesmann, Olive AL, MD
Miller, George Stuart, MD
Nebab, Nester C, MD
Patel, Purushottam C, MD
Payumo, Carmelino C, MD
Romano, Joseph P, MD
Salcie, Francisco A, MD
Singer, Jack M, MD
Tan, Evelyn R, MD
Turkish, Sheldon C, MD
Uchida, Toru A, MD
Weinberg, Frederick M, MD
Wu, Jung-Yi, MD
Monmouth County
Colmer, Marc E, MD
Gopalakrishnan, Sivasubramaniam,
MD
Hong, Sunok, MD
Knapp, Herbert Arnold, MD
Morgenstern, Alvin H, MD
Ollins, Gerald H, MD
Pertchik, Alan F, MD
Pomerantz, Allen C, MD
Rangam, Tsui H, MD
Scher, Charles Z, MD
Wandycz, Tadeusz, MD
Morris County
Chen, Wen L, MD
Crotty, Martin J, MD
Englestein, Eric Steven, MD
Falbo, Ann, MD
Gerwin, Kenneth S, MD
Hnat, Richard F, MD
Kidwell, Allyn Perry, MD
Lim, Dong-Won, MI)
Menkin, Allen, MD
Michelstein, Martin A, MD
Migliardi, Joseph R, MD
Olivia, Joseph V, MD
Penek, John, MD
Uygur, Ihsan Mustafa, MD
Wallis, Joseph J, DO
Waran, Sandy P, MD
Yazdan-Parasti, Esfandiar, MD
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
Ocean County
El-Kharboutly, Mohamed M, MD
Lygas, Theodore B, MD
Motley, John Paul, MD
Pittella, Anna N, MD
Schenker, Samuel D, MD
Scher, Stephen M, MD
Passaic County
Bautista, Estrella D, MD
De Silva, Nihal K, MD
Kang, Byung K, MD
Mohtashemi, Hormoz, MD
Morski, Richard, MD
Nelson, Geraldine I, MD
Pajoohi, Manoochehr, MD
Pajoohi, Soheil, MD
Rapacon, Magdaleno R, MD
Tandon, Ramesh C, MD
Toombs, James Raye, MD
Tseng, William P, MD
Uhm, Kyudong, MD
Wu, YieuC, MD
Salem County
De Castro, Amante, MD
134
NEW JERSEY MEDICINE
Park, Young Ja, MD
Somerset County
Beiter, Deborah A, MD
Chaudhry, Mohammad A, MD
Choi, Chanam L, MD
Ohki, Stephen K, MD
Sussex County
De Long, II, Donald H, MD
Digby, Thomas E, MD
Shivashankara, Birur M, MD
Sugar, Donald Andrew, MD
Union County
Archer, Rudolph, MD
Baird, Harry Leverton, MD
Liemer, Martin Daniel, MD
Mehta, Uday C, MD
Zarafu, liana W, MD □
■■ PLACEMENT FILE Hi
The following physicians have
written to the Executive Offices of
MSNJ seeking information on
possible opportunities for practice
in New Jersey. The information
listed below has been supplied by
the physicians. If you are inter-
ested in any further information
concerning these physicians, we
suggest you make inquiries directly
to them.
ANESTHESIOLOGY
Hak Joo Cha, MD, 22 Hamilton Ct.,
Lawrenceville, NJ 08648. Catholic
Medical College 1972. Board eligible.
Solo, partnership, group, fee-for-ser-
vice. Available.
CARDIOLOGY
Fredric Gerewitz, MD, 125 Montgom-
ery Ave., Bala Cynwyd, PA 19004.
SUNY-Downstate 1984. Board eligi-
ble. Group or partnership. Available
July 1990.
Matilda M. Taddeo, MD, 2269 Ellis
Ave., Bronx, NY 10462. West Indies
1983. Board eligible. Group or partner-
ship. Available.
GASTROENTEROLOGY
Eric Avezzano, MD, 2510 B.S. Walter
Reed Dr., Arlington, VA 22206. SUNY-
Stony Brook 1985. Board eligible;
board certified (IM). Group, partner-
ship, solo. Available July 1990.
INTERNAL MEDICINE
Albert S. Ford, MD, 943 Norway Ave.,
Huntington, WV 25703. Meharry
Medical College 1982. Board eligible.
Solo or practice purchase. Available
June 1990.
Himanshu Shah, MD, 71 Louis St.,
New Brunswick, NJ 08901. UMDNJ
1988. Part-time position. Available.
NUCLEAR MEDICINE
Robert W. Cifers, MD, 26 Somers
Ave., Seaville, NJ 08230. Ohio State
1983. Board eligible. Available.
OTOLARYNGOLOGY
Samuel H. Selesnick, MD, 450 East
63rd St., #8F, New York, NY 10021.
NYU 1985. Board eligible. Available
July 1990.
PATHOLOGY
Ruth Kreitzer-Richards, MD, 5470
Mosholu Ave., Riverdale, NY 10471.
Guadalajara 1983. Board certified.
Available July 1990.
1990 MSNJ ANNUAL MEETING
Saturday, May 5, 1990
3:30 p.m. Board of Trustees’ Meeting
7:00 p.m. Officers’ Cocktail Reception and Dinner
Sunday, May 6, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
10:00 a.m. Educational Program
11:00 a.m. Exhibits Open
1:00 p.m. House of Delegates
3:30 p.m. Reference Committee Meetings
Monday, May 7, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates (Election)
12:00 noon Golden Merit Award Ceremony and Reception
1:00 p.m. Professional Liability Program (MIIENJ)
2:45 p.m. Reference Committee Meetings
5:00 p.m. JEMPAC Political Forum
5:45 p.m. JEMPAC Wine and Cheese Reception
6:30 p.m. Somerset County Medical Society
Tuesday, May 8, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates
1:30 p.m. House of Delegates
2:00 p.m. Exhibits Close
6:30 p.m. Inaugural Reception and Dinner
Wednesday, May 9, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. General Session
1 .00 p.m. Board of Trustees’ Meeting
VOL. 87— NUMBER 2 FEBRUARY 1990
135
HOUSING APPLICATION
224th ANNUAL MEETING
MEDICAL SOCIETY OF NEW JERSEY
MAY 6-9, 1990
Select the hotel of your choice. Mail the entire form with one night’s deposit to that hotel.
THE SANDS HOTEL, CASINO & COUNTRY CLUB (Headquarters Hotel)
INDIANA AVE. AT BRIGHTON PARK, P.O. BOX 28, ATLANTIC CITY, NJ 08404
RESERVATION DEPARTMENT 1-800-257-8580
(Please Print)
Name
Address
City State Zip
Home Phone Business Phone
Sharing With
Date of Arrival Time
Date of Departure Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the SANDS or complete the following:
American Express No. Expiration Date
SCHEDULE OF RATES SUBJECT TO 12% TAX
□ SINGLE $75.00 □ One-Bedroom Suite $225.00 □ Two-Bedroom Suite $300.00
□ DOUBLE $75.00 (Reservations must be received prior to April 6, 1990)
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
CLARIDGE CASINO HOTEL
INDIANA AVE. AT THE BOARDWALK, P.O. 448, ATLANTIC CITY, NJ 08404
RESERVATION DEPARTMENT (609) 340-3434
NJ ONLY 1-800-582-7676
(Please Print)
Name
Address
City State Zip
Home Phone Business Phone
Sharing With
Date of Arrival Time
Date of Departure Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the CLARIDGE or complete the following:
Card #_ Type Exp. Date
SCHEDULE OF RATES SUBJECT TO 12% TAX
□ SINGLE $75.00 □ One-Bedroom Suite $225.00 □ Two-Bedroom Suite $300.00
□ DOUBLE $75.00 (Reservations must be received prior to April 5, 1990)
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
136
NEW JERSEY MEDICINE
CONTINUING EDUCATION
ANESTHESIOLOGY
March
24- Annual Postgraduate
25 Anesthesia Seminar
All day — The Hyatt, Cherry Hill
(New Jersey State Society of
Anesthesiologists)
CARDIOLOGY
March
14 Advanced Cardiac Life Support
21 All day — Freehold Area Hospital,
Freehold
(Freehold Area Hospital)
DERMATOLOGY
March
21 Robert Wood Johnson
Medical School
Dermatological Conferences
6-9 P.M. — Rutgers Community
Health Plan, US #1,
New Brunswick
(UMDNJ)
April
18 Robert Wood Johnson
Medical School
Dermatological Conferences
6-9 P.M. — Rutgers Community
Health Plan, US #1,
New Brunswick
(UMDNJ)
INFECTIOUS DISEASE
April
4 Counseling and Testing for HIV
Infection
11:30 A. M. -12:30 P.M. — Rahway
Hospital, Rahway
(AMNJand NJDOH)
20 Clinical Management of HIV
Infection
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJand NJDOH)
MEDICINE
March
1 Colitis
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
2 Continuing Medical
9 Education Program
16 12 Noon-1 P.M. —South Jersey
23 Hospital System, Bridgeton
30 (South Jersey Hospital System)
6 Fourth Annual Internal
13 Medicine Update and
20 Board Review
27 5:30-7:30 P.M. — Cooper Hospital,
Camden
(Cooper Hospital/UMDNJ)
7 Internal Medicine
14 Review7 Course
21 4-7 P.M. — University Hospital,
28 New Brunswick
(AMNJand UMDNJ)
7 Diabetes-Related
Kidney Disease
10:30-11:30 A. M. — St. Mary’s
Hospital, Passaic
(AMNJ and NJDOH)
7 Prevention of Lower Extremity
Amputations
11:30 A. M. -12:30 P.M. —Rahway
Hospital, Rahway
(AMNJ and NJDOH)
7 Medical Lecture Series
14 10:30-11:30 A. M— Christ
21 Hospital, Jersey City
28 ( Christ Hospital)
8- Annual Meeting and Scientific
1 1 Assembly, New Jersey Academy
of Family Physicians
Caesar’s Palace, Atlantic City
(NJ Academy of Family
Physicians)
8 Update on Geriatric Medicine
22 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
9 Alcoholism
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
9 Functional Assessment
of the Elderly
10:30-11:30 A.M.— Christ
Hospital, Jersey City
(AMNJ)
9 Rheumatology Case
Presentation Conference
12:15-1:15 P.M. — Kennedy
Memorial Hospital, Stratford
(UMDNJ and Kennedy Memorial
Hospital)
12 Thyroid Disease
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
13 Renal Biopsy Conferences
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
14 Dialogues in Critical Medical
Decisions
7:30-9 P.M. — Englewood Hospital,
Englewood
(Englewood Hospital)
14 Diabetes-Related
Kidney Disease
11.-30-A.M. -12:30 P.M. —Rahway
Hospital, Rahway
(AMNJ and NJDOH)
14 Chronic EBV Virus
10:30-11:30 A.M. — University
Hospital, New Brunswick
(AMNJ)
15 Diabetes-Related Kidney
Disease
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
15 Aspiration Syndrome in the
Mentally Retarded
1:30-2:30 P.M. — Vineland
Developmental Center, Vineland
(AMNJ)
15 Continuing Medical Education
Series
12 Noon — Somerset Medical
Center, Somerville
(Somerset Medical Center)
16 Management of Abdominal
Emergencies
1-2 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
17- Annual Meeting, American
18 College of Emergency
Physicians
All day — Trump Plaza Hotel &
Casino, Atlantic City
(American College of Emergency
Physicians)
VOL. 87— NUMBER 2 FEBRUARY 1990
139
JEFFERSON MEDICAL COLLEGE
OF
THOMAS JEFFERSON UNIVERSITY
Department of Neurology
presents
Reflex Sympathetic
Dystrophy: Current
Strategies in Diagnosis
and Treatment
March 9 and 10, 1990
at
Jefferson Medical College
McClellan Hall
Program Directors:
Robert J. Schwartzman, M.D.
Robert L. Knobler, M.D., Ph.D.
Audrey F. Thomas, B.A., R.N.
For further information contact:
The Office of Continuing Medical Education
1025 Walnut Street, Room G3
Philadelphia, PA 19107
215-928-6992
Advanced Management
Program for Clinicians
at NYU
AMPC is a Master’s Degree program for clinicians
who want to build the skills that will allow them
to act upon (rather than just react to) changes in
the health care sector. AMPC:
• Leads to an MS degree in health policy and
management.
• Provides training in financial analysis,
quality assurance, information systems,
marketing, management, policy and more.
• Offers courses in the evenings and on Sat-
urdays to accommodate clinicians’ busy
schedules.
For more information about AMPC, call
(212) 998-7460.
A American
Diabetes
. Association,
Greater Philadelphia Affiliate
Presents
Annual Scientific Symposium
March 17, 1990
Four Seasons Hotel, Philadelphia
Main Lecturer and Honoree: Arthur H. Rubenstein, M.D.
Topic: Pro Insulin, C-Peptide, and Amylin in Diabetes
Other Topics Include: “Lipids and Diabetes”
“Update on Pregnancy and Diabetes”
“Diabetes and Exercise: Therapeutic Implications”
“Albuminuria, Hypertension, and the Genesis of Diabetic
Kidney Disease”
For More Information Call: Lynette Lawrence (215) 557-8070
140
NEW JERSEY MEDICINE
17 Morbidity and Mortality
24 Conference
8:30-10 A.M. — New Jersey
Medical School, Newark
(UMDNJ)
20 Renal Adaptation to Ventilatory
Response to Metabolic Acid-
Base Disorders
6:30-9:30 P.M. — Overlook
Hospital, Overlook
( AMNJ )
21 Retinopathy
11:30 A.M. -12:30 P.M. —Rahway
Hospital, Rahway
(AMNJ)
22 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
30 Clinicopathologic Case
Presentation
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
April
3 Fourth Annual Internal
17 Medicine and Board Review
24 5:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
4 Living Wills
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
4 Medical Lecture Series
11 10:30-11:30 A.M. —Christ
18 Hospital, Jersey City
25 ( Christ Hospital)
4 Internal Medicine
1 1 Review Course
18 4-7 P.M. — University Hospital,
25 New Brunswick
(AMNJ and UMDNJ)
5 Immunology
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
6 Burns
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
6 Continuing Medical
13 Education Program
20 12 Noon-1 P.M. — South Jersey
27 Hospital System, Bridgeton
(South Jersey Hospital System)
10 Renal Biopsy Conferences
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
1 1 Dialogues in Critical Medical
Decisions
7:30-9 P.M. — Englewood Hospital
(Englewood Hospital)
12 Update on Geriatric Medicine
26 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
17 Unresolved Problems in Acute
Renal Failure
6:30-9:30 P.M. — Overlook
Hospital, Overlook
(AMNJ)
18 Fluid and Electrolyte Disorders
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
18 Amputee Rehabilitation and
Prevention
2-3 P.M. — John E. Runnells
Hospital of Union County,
Berkeley Heights
(AMNJ)
19 Nephropathy
2-3 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
19 Continuing Medical
Education Series
12 Noon — Somerset Medical
Center, Somerville
(Somerset Medical Center)
19 Endocrinology
11 A.M. -12 Noon — St. Joseph’s
Hospital and Medical Center,
Paterson
(St. Joseph’s Hospital and
Medical Center)
20 Drug-induced Lupus
12:15-1:15 P.M. — Kennedy
Memorial Hospital, Stratford
(UMDNJ and Kennedy Memorial
Hospital)
21 Morbidity and Mortality
28 Conference
8:30-10 A.M. — New Jersey
Medical School, Newark
(UMDNJ)
21- Advances in Gastrointestinal
22 Disorders
8 A.M. -5 P.M. — Robert Wood
Johnson Medical Center,
Piscataway
(UMDNJ)
23 Nephropathy
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
26 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
26- Lyme Disease Symposium
27 8:30 A.M. -5 P.M. — Robert Wood
Johnson Medical School,
Piscataway
(UMDNJ)
OBSTETRICS AND GYNECOLOGY
March
9- Annual Semmelweiss-Waters
11 Ob/Gyn Conference
8 A.M. -5 P.M. — Bally’s Grand
Hotel, Atlantic City
(UMDNJ)
ONCOLOGY
March
9 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
14 Tumor Board Conference
11 A.M. -12 Noon — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
22 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
28 Dinner Meeting
6:30-9:30 P.M. —The Hyatt,
New Brunswick
(Radiation Oncology Section—
AMNJ)
April
1 1 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
13 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
26 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
26 Dinner Meeting
6:30-9:30 P.M. — The Hyatt,
New Brunswick
( AMNJ — Head and Neck
Oncology Section)
ORTHOPEDICS
April
17- Annual Spring Meeting
22 Royal Antiqua Hotel, Antiqua
(New Jersey Orthopaedic Society)
PEDIATRICS
March
1 Pediatric Grand Rounds
8 8:30-9:30 A.M. — Robert Wood
15 Johnson Medical School, MEB,
22 102, New Brunswick
29 (UMDNJ)
VOL. 87— NUMBER 2 FEBRUARY 1990
141
Hahnemann University
Department of Medicine
WEDNESDAYS GRAND ROUNDS
8:30 A.M.-9:30 A.M.
February-May 1990
FEBRUARY 1990
February 7, 1990
SOMATOSTATIN, CARCINOID SYNDROME
John Oates, M.D.
Professor & Chairman
Department of Medicine
Vanderbilt University
February 14, 1990
LYME DISEASE
Steven Blllsteln, M.D., MPH
Associate Professor of Medicine
Columbia Presbyterian Medical Center
February 21, 1990
NEOPLASTIC DISEASE ADVANCES
IN THERAPY
Isadora Brodsky, M.D.
Professor of Medicine
Department of Neoplastic Diseases
Director, Institute of Cancer & Blood Diseases
Hahnemann University
February 28, 1990
CLINICAL PATHOLOGIC CONFERENCE
Chief Residents:
Michael DeAngelis, M.D.
Ana Nunez, M.D
Ralph McKIbben, M.D
Matthew Sandler, M D
MARCH 1990
March 7, 1990
IMMUNE INTERVENTION IN TYPE I DIABETES
MELLITUS
Jay S. Skylar, M.D.
Professor of Medicine
Director, Diabetes Mellitus
University of Miami
March 14, 1990
COPD: PATHOGENESIS AND TREATMENT
ADVANCES
Mark J. Utell, M.D.
Professor of Medicine and Toxicology
University of Rochester
March 21, 1990
CLINICAL PHARMACOLOGY
Vincent J. Zarro, M.D., Ph.D.
Associate Professor of Pharmacology & Medicine
Director, Division of Clinical Pharmacology
Hahnemann University
March 28,1990
DERMATOLOGIC TREATMENT WITH RETINOIDS
AND CYCLOSPORINE
Richard L. Splelvogel, M.D.
Professor of Medicine and Dermatology
Director, Division of Dermatology
Hahnemann University
APRIL 1990
April 4, 1990
CARDIAC ELECTROPHYSIOLOGY: EVOLVING
DIAGNOSTIC AND THERAPEUTIC MODALITIES
John D. Fisher, M.D.
Professor of Medicine
Director, Cardiac Arrhythmia Service
Acting Director, Division of Cardiology
Montefiore Medical Center
April 11, 1990
MEDICAL MANAGEMENT OF GALLSTONE
DISEASE
Hans Fromm, M.D.
Professor of Medicine
Director, Division of Gastroenterology
The George Washington University
April 18, 1990
ENDOCRINOLOGY AND METABOLISM: RECENT
ADVANCES
Leslie I. Rose, M.D.
Professor of Medicine
Director, Division of Endocrinology and
Metabolism
Jeffrey L. Miller, M.D.
Associate Professor of Medicine
Division of Endocrinology and Metabolism
Hahnemann University
April 25, 1990
TREATMENT OF DIFFICULT GRAM
NEGATIVE BACTERIAL INFECTIONS
William E. Dlsmukes, M.D.
Professor & Vice Chairman for Educational
Programs
Department of Medicine
University of Alabama
1990— WEDNESDAY— 1990
MEDICAL SEMINAR SERIES
8:30 A.M.-3:00 P.M.
March 7, 1990
DIABETES MELLITUS: Immune Mechanisms & Insulin Therapy
Innovations
March 28, 1990
DERMATOLOGY: Treatment with Retinoids and Cyclosporine
April 25, 1990
DIFFICULT GRAM NEGATIVE AND FUNGAL INFECTIONS
May 9, 1990
IMMUNOTHERAPY AND KIDNEY TRANSPLANTATION
Presented by:
William S. Frankl, M.D.
Professor of Medicine and Chairman
Department of Medicine
Allan B. Schwartz, M.D.
Professor of Medicine and
Director, Continuing Medical Education
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd Floor— College Bldg.
Hahnemann University
15th Street Entrance
15th and Vine Streets
Philadelphia, PA
We wish to acknowledge educational support from:
E.R Squibb & Sons
Merck, Sharpe & Dohme
Burroughs Wellcome & Co.
Squlbb-Novo
Sandoz
Roche
CIBA-Gelgy
Approved for CME credits through the Office of Continuing Education, Hahnemann University
For further information: (215) 448-8263
I
142
NEW JERSEY MEDICINE
20 Third Annual Perspectives on
Sudden Infant Death Syndrome
8:30 A. M. -3:15 P.M.— Robert
Wood Johnson Medical School,
Piscataway
(UMDNJ)
21 Neonatal Resuscitation and
Stabilization
7:30 A. M. -5:15 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
22 Update in Aspects of Pediatrics
Marriott Hotel, Saddle Brook
(Northern NJ Pediatric Society)
22 Children’s Vision Disorders
8:30 A. M. -3:30 P.M. —Robert
Wood Johnson Medical School,
Piscataway
(UMDNJ)
April
5 Pediatric Grand Rounds
12 8:30-9:30 A. M. — Robert Wood
19 Johnson Medical School, MEB,
26 102, New Brunswick
(UMDNJ)
11 Learning Disabilities
10:30-11:30 A. M.— St. Mary’s
Hospital, Passaic
(AMNJ)
18 Neonatal Resuscitation and
Stabilization
7:30 A. M. -5:15 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
19 Update in Aspects of Pediatrics
Marriott Hotel, Saddle Brook
(Northern NJ Pediatric Society)
PSYCHIATRY
March
1 Case Seminars To Improve
15 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
6 Psychiatry Grand Rounds
13 8:30-10 A. M. — Elizabeth General
20 Medical Center, Elizabeth
27 ( Elizabeth General Medical
Center)
16 Teenage Suicide
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
( South Jersey Hospital System)
April
3 Psychiatry Grand Rounds
10 8:30-10 A. M. — Elizabeth General
17 Medical Center, Elizabeth
24 (Elizabeth General Medical
Center)
5 Case Seminars To Improve
19 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
18 Psychiatry and the Law’
10:30-11:30 A. M. — St. Mary’s
Hospital, Passaic
(AMNJ)
PULMONOLOGY
March
2 18th Annual Joint Conference
New Jersey Thoracic Society/
New Jersey Chapter of the
American College of Chest
Physicians
Hyatt Regency, New Brunswick
(New Jersey Thoracic Society)
RADIOLOGY
March
15 1989-1990 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of
New Jersey-Diagnostic Section,
AMNJ)
22 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
31 Seeing the Unseen: Noninvasive
Vascular Imaging in the 90s
8 A.M.-4 P.M. — The Ramada
Renaissance, East Brunswick
(AMNJ)
April
19 1989-1990 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of New
Jersey-Diagnostic Section,
AMNJ)
26 Visiting Professor Program
1:30-5 P.M. —Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
SURGERY AND ITS SPECIALTIES
March
4 Surgical Treatment of
Cardiothoracic Disease
10-11:30 A.M. — New Jersey
Medical School, MSB,
506B, Newark
(UMDNJ)
6 Weekly Vascular Case
13 Conference
20 7:30-8:30 A.M. — Robert Wood
27 Johnson Medical School, MEB,
108B, New Brunswick
(UMDNJ)
17 Morbidity and Mortality
24 Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
27 Englewood Surgical Society
Lecture Series
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society)
28 Journal Club, Section of
Cardiothoracic Surgery
6:30-9:30 P.M. — 2 Mountain
Ridge Drive, Livingston
(UMDNJ)
April
1 Surgical Treatment of
Cardiothoracic Disease
10-11 A.M. — New Jersey Medical
School, MSB, 506B, Newark
(UMDNJ)
3 Weekly Vascular Case
10 Conference
17 7:30-8:30 A.M. — Robert Wood
24 Johnson Medical School, MEB,
108B, New Brunswick
(UMDNJ)
21 Morbidity and Mortality
28 Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
24 Englewood Surgical Society
Lecture Series
8-1° P.M. — Englewood Club,
Englewood
(Englewood Surgical Society)
25 Journal Club, Section of
Cardiothoracic Surgery
6:30-9:30 P.M. — 2 Mountain Ridge
Drive, Livingston
(UMDNJ)
UROLOGY
March
2 Urology Grand Rounds
9 New Jersey Medical School,
16 MSB, C600, Newark
23 (UMDNJ)
30
21 Urinary Tract Infections
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
April
6 Urology Grand Rounds
13 New Jersey Medical School,
20 MSB, C600, Newark
27 (UMDNJ)
18 Annual William P. Burpeau
Award Dinner and Lecture
6 P.M. — The Manor, West Orange
(AMNJ)
VOL. 87— NUMBER 2 FEBRUARY 1990
143
■N
PHILADELPHIA HEART INSTITUTE
of Presbyterian Medical Center
I Cardiology
Update
designed for the physician and provides an intensive
survey of the current status of clinical cardiology. . .
Wednesday, March 7, 1990
Controversy: Sudden Death — Is Electrophysiologic
Testing Preferred Over
Conventional Evaluation?
Charles Gottlieb , M.D.
Philip J. Podrid, M.D
Walter R. Hepp, M.D
Moderator
Leonard N. Horowitz, M.D.
3:00-3:30 Yes
3:30-4:00 No
4:00-5:00 Case presentations — The resuscitated patient —
Panel discussion
Michael S. Feldman, M.D.
Robert I Katz, M.D.
Steven J. Nierenberg, M.D.
■ Case Presentations and Panel Discussions
■ CME Credits*
■ No Registration Fee
■ Call for Reservation 2 / 5-662-862 7
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
’‘The Philadelphia Heart Institute at Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
"The University of Pennsylvania School of Medicine is accredited by the Accreditation Council for Continuing Medical
Education to sponsor continuing medical education for physicians. The University of Pennsylvania School of Medicine
designates this Continuing Medical Education activity for 2 credit hours per session in Category 1 of the Physician's
Recognition Award of the American Medical Association."
J
144
NEW JERSEY MEDICINE
IN MEMORIAM
Edward C. Edlkraut. Word has
been received noting the death of
Edward Coleman Edlkraut, MD,
on November 10, 1989. Dr.
Edlkraut, a retired member of our
Passaic County component, was
born in 1907 in Passaic. He re-
ceived his medical degree from
Georgetown Medical School,
Washington, DC, in 1931, and was
awarded his New Jersey license the
following year. A pediatrician, Dr.
Edlkraut was affiliated with Pas-
saic General Hospital until his re-
tirement to Florida in 1974. Dr.
Edlkraut served in the United
States Air Force from 1942 to 1946,
attaining the rank of captain.
C. Clayton Griffin. At the un-
timely age of 35, Charles Clayton
Griffin, MD, died on November 19,
1989. Dr. Griffin was head of the
regional trauma center at Univer-
sity Hospital, Newark. He was
considered the “architect” of the
five-year program. Dr. Griffin also
was instrumental in helping to es-
tablish the JEMSTAR Program,
that placed one helicopter in New-
ark and one helicopter in Voorhees
to provide complete medical rescue
service for all of New Jersey. He
was a member of our Essex County
component, and of the American
Medical Association, and was a fel-
low of the American College of Sur-
geons. Born in 1953, Dr. Griffin
earned his medical degree at
Tulane University Medical School,
Louisiana, in 1978. He served an
internship and residency at
Maricopa County General Hospi-
tal, Arizona, from 1978 to 1983,
and then relocated to New Jersey
to complete a fellowship in trauma
surgery at UMDNJ. Dr. Griffin
was awarded his license to practice
in New Jersey in 1983. He was an
assistant professor of surgery at
UMDNJ-New Jersey Medical
School, president of the University
Hospital medical staff, and a key
representative on the planning
board of UMDNJ’s new medical
office complex.
Floyd B. Gusack. At the un-
timely age of 55, Floyd Bruce
Gusack, MD, a member of our
Union County component, died on
September 29, 1989. Born in
Brooklyn, New York, Dr. Gusack
received his medical degree from
Hahnemann Medical College,
Pennsylvania, in 1959, and was
awarded his New Jersey license in
1960. After serving an internship at
Muhlenberg Hospital, Plainfield,
Dr. Gusack was an attending in
ophthalmology at New York Eye
and Ear Infirmary, Raritan Valley
Hospital, Green Brook, John F.
Kennedy Medical Center, Edison,
and Muhlenberg Hospital. A
diplomate of the American Board
of Ophthalmology, Dr. Gusack was
a member of the AMA, and a Fel-
low of the American College of
Ophthalmology.
Elias J. Hatem. Former chief of
surgical services at St. Joseph’s
Hospital and Medical Center,
Paterson, Elias Joseph Hatem,
MD, died on September 29, 1989.
Before he retired in 1974, Dr.
Hatem had a private medical and
surgical practice in Paterson. Born
in 1905 in Lebanon, Dr. Hatem
and his family emigrated to the
United States in 1909. He received
his medical degree from Tufts Uni-
versity Medical School, Massachu-
setts, in 1929 and served an in-
ternship at St. Joseph’s Hospital
and Medical Center in 1929; the
following year he joined the medi-
cal staff, and in 1973, St. Joseph’s
Hospital and Medical Center
honored him with the Distin-
guished and Outstanding Service
Award. A retired member of our
Passaic County component, Dr.
Hatem was a fellow of the Ameri-
can College of Surgeons, and a
member of the AMA Association.
Albert Lewis. At the age of 89,
Albert Lewis, MD, of Cranford, a
member of our Union County com-
ponent, died on October 28, 1989.
Born in 1900 in Brooklyn, New
York, Dr. Lewis was graduated
from the Long Island College
Medical School, in 1928, and re-
ceived his license to practice medi-
cine in New Jersey in 1929. Dr.
Lewis was the oldest practicing
physician in Union County when
he retired in 1986; he was affiliated
with three Elizabeth institutions:
Alexian Brothers Hospital, St.
Elizabeth Hospital, and Elizabeth
General Medical Center. A family
practitioner, Dr. Lewis was a mem-
ber of the American Medical As-
sociation and of the Academy of
Medicine of New Jersey.
Aaron Lowenstein. A member
of our Essex County component,
Aaron Lowenstein, MD, died on
November 6, 1989. Born in 1903 in
Russia, Dr. Lowenstein was
awarded his medical degree at the
State University of South Carolina
Medical School in 1926; and re-
ceived his medical license to prac-
tice in New Jersey in 1927. An ob-
stetrician-gynecologist, Dr. Low-
VOL. 87— NUMBER 2 FEBRUARY 1990
147
enstein was chief of his department
at Newark Beth Israel Medical
Center until retiring in 1973; while
at the Medical Center, he pio-
neered the practice of continuous
caudal anesthesia. After his retire-
ment, he served as medical direc-
tor of the North Jersey Community
Union Clinic in Newark for eight
years. Dr. Lowenstein was a mem-
ber of the American Medical As-
sociation and was a fellow of the
American Academy of Obstetrics
and Gynecology.
Louis R. Panigrosso. At the
grand age of 90, Louis Rocco Pan-
igrosso, MD, died on September
30, 1989. Born in Avelino, Italy,
Dr. Panigrosso moved to Perth
Amboy over 50 years ago. He was
awarded his medical degree from
St. Louis Medical School, Mis-
souri, in 1930 and his New Jersey
license in 1931. He was affiliated
with Perth Amboy General Hospi-
tal and St. Peter’s Medical Center,
New Brunswick. Also, he served as
an educator at the Charles E.
Gregory School of Nursing. A re-
tired member of our Middlesex
County component, Dr. Panigrosso
was a member of the American
Medical Association, and a fellow
of the International College of Sur-
geons and of the American College
of Obstetrics and Gynecology. He
served as a navy captain in World
War II.
Elizabeth C. Quinn. At the un-
timely age of 37, Elizabeth Carol
Quinn, MD, of Edison, died on No-
vember 5, 1989. Dr. Quinn was a
physician and medical educator of
infectious disease at Muhlenberg
Regional Medical Center, Plain-
field. She had been on the staff of
the Medical Center for six years; in
addition, Dr. Quinn was a clinical
associate professor at UMDNJ-
Robert Wood Johnson Medical
School. Born in 1952 in Cranford,
Dr. Quinn was awarded her medi-
cal degree at UMDNJ-Rutgers
Medical School in 1978; she re-
ceived her New Jersey license the
following year. Dr. Quinn was a
member of our Union County com-
ponent, and a fellow of the Ameri-
can Society for Microbiology and
of the American College of Physi-
cians. In 1988, Dr. Quinn was the
recipient of the Outstanding At-
tending Physician Award pre-
sented by Muhlenberg Regional
Medical Center.
Aaron W. Rosendale. Retired
physician Aaron William Rosen-
dale, MD, died on November 11,
1989, at the age of 71. Born in
Paterson, Dr. Rosendale earned his
medical degree at Marquette Uni-
versity School of Medicine, Wis-
consin, in 1953, and in 1954 was
awarded his New Jersey license. A
family physician, Dr. Rosendale
maintained a private practice in
Paterson and for 25 years, was the
administrative director of the
Christian Care Center in Wyckoff.
Dr. Rosendale retired from active
practice in 1984; he was a member
of our Passaic County component
and of the American Medical As-
sociation.
Abraham B. Sand. Word has
been received of the death of
Abraham B. Sand, MD, on July
16, 1989. Born in 1908 in Ohio, Dr.
Sand was awarded his medical
degree from Temple University
Medical School, Philadelphia, in
1933, and received his New Jersey
license in 1937. A retired member
of our Burlington County compo-
nent, Dr. Sand was a family practi-
tioner affiliated with Memorial
Hospital of Burlington County,
Mount Holly. In addition, he was
a member of the American Medi-
cal Association.
Edward P. Shope. A member of
our Camden County component,
Edward Pierce Lentz Shope, MD,
died on November 5, 1989. Born in
1896, in Pennsylvania, Dr. Shope
received his medical degree from
Johns Hopkins University School
of Medicine, Maryland, in 1920;
three years later he was awarded
his license to practice in New
Jersey. An ophthalmologist, Dr.
Shope had a private practice in
Haddonfield, and was affiliated
with Wills Eye Hospital and Jef-
ferson Hospital, both in Philadel-
phia. Dr. Shope was a diplomate of
the American Board of Ophthal-
mology and a member of the AMA.
Irving Shulman. The chief of
urology at Greenville Hospital and
the Jewish Hospital and Rehabili-
tation Center, both in Jersey City,
Irving Shulman, MD, died on No-
vember 7, 1989. Born in 1923 in
Brooklyn, New York, Dr. Shulman
earned his medical degree at
Tulane Medical School, Louisiana,
in 1946; he received his New Jersey
medical license in 1948. Dr.
Shulman was a diplomate of the
American Board of Urology; a fel-
low of the American College of Sur-
geons, of the American Association
of Clinical Urology, and of the
American Society of Abdominal
Surgeons; and a member of our
Hudson County component and of
the American Medical Association.
In addition, Dr. Shulman was the
former chief of the Department of
Urology, Christ Hospital, Jersey
City; on the staffs of Pollack Hos-
pital, Fairmount Hospital, and St.
Francis Hospital, all in Jersey
City, and North Hudson Hospital,
Weehawken.
Thomas A. Stanley. Word has
been received of the death of
Thomas A. Stanley, MD, on
August 6, 1989. Born in 1917 in
East Orange, Dr. Stanley was
awarded his medical degree in 1943
from the New York University Col-
lege of Medicine. He received his
license to practice in New Jersey in
1946, after serving in the Navy as
a lieutenant. A general surgeon,
Dr. Stanley was affiliated with
St. Mary’s Hospital, Orange, and
Presbyterian Hospital, Newark.
Dr. Stanley was a diplomate of the
American Board of Surgery, and a
member of our Essex County com-
ponent and of the AMA.
148
NEW JERSEY MEDICINE
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
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Assignment of Copyright. In
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Material taken from other publi-
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VOL. 87— NUMBER 2 FEBRUARY 1990
151
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parking spaces. Busy, busy, thoroughfare. Between
St. Barnabas and Morristown Memorial, available for
occupancy March 1. Reasonable rent.
Call M.T. Papa Associates 201-887-3393.
CREATE A MEDICAL
BREAKTHROUGH.
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152
NEW JERSEY MEDICINE
MSNJ
NEWSLETTER
PRO LEGAL DEFENSE The Medical Society of New Jersey Endorsed Peer Review Organization
PROGRAM COVERAGE Legal Defense Program has been expanded to provide legal defense
before certified quality review organizations at no additional cost to the
physician. Now, virtually every physician will benefit from this program.
The program is provided by the law firm of Kern Augustine Conroy &
Isele. For a $190 annual fee, the firm provides legal representation when-
ever the peer review organization (PRO) or any other certified quality
review organization (QRO), acting by state mandate, issues an initial
determination questioning the quality or necessity of services rendered.
The program provides full representation through all phases of the ad-
ministrative process, through review by the inspector general of the
United States (DHHS).
The Medical Society continues to review and monitor the activities of
the PRO. Based upon that review, the Society is convinced that every
practicing physician is in substantial jeopardy when faced with a PRO
or QRO review. No physician should engage in any dialogue with the
PRO without the benefit of competent legal counsel. The PRO Legal
Defense Program is the most effective and least costly way to obtain that
protection. For more information, contact Kern Augustine Conroy &
Isele at 201/984-0101,
COLLECTION A seminar entitled, “Inside Information on Collection,” sponsored by the
INFORMATION New Jersey Society of Medical Assistants, will feature Dick Saari, BBA-
SEMINAR Marketing, vice-president SaVit Collection Agency, Editor-Collection
News. The program will be held on Thursday, April 12, 1990, at MSNJ
headquarters, from 9:30 A. M. -3:30 P.M. with lunch included. The deadline
for reservations is March 30, 1990. For information, contact Linda Wells,
CMA, 609/779-1397 or Jamie Brodeur, CMA, 609/893-0741.
MATERNITY OUTREACH Maternity Outreach and Managed Services Program (MOMS) works to
PROGRAM reduce the incidence of birth complications, infant mortality, and low
birthweight in New Jersey. Hospitals that provide Healthstart services
are eligible to offer MOMS services. Like Healthstart, the MOMS pro-
gram offers case-management services, social/psychological assessment,
nutritional assessment and health education, home visits, and referral
to other healthcare providers. Other services would be tailored to the
specific needs of the patient. Unlike Healthstart, the MOMS program
is available to any interested, pregnant woman in New Jersey and will
be partially funded through the Uncompensated Care Trust Fund.
Healthstart is available only to Medicaid eligible pregnant women and
is completely funded by Medicaid.
MOMS services will be offered to women with incomes under 150 percent
of the poverty level at no charge. Hospitals providing MOMS services
to women below the poverty level can write off the charges to charity
care. Women with higher incomes will be charged a sliding fee. The fee
amount not charged to the patient should be written off to charity care.
Women with incomes in excess of 250 percent of the poverty guideline
will not be eligible for a discounted fee.
VOL. 87— NUMBER 3 MARCH 1990
163
The Department of Health has recommended a $351 rate per case for
hospital provision of MOMS comprehensive prenatal health support
services for the 1990 rate year. The $351 rate will be updated by the
economic factor for subsequent rate years. The Department of Health
expects savings from the MOMS program primarily through reduced
costs of newborn care associated with preterm and low birthweight
babies, and from a reduction in infant rehospitalizations in the first year
of life.
BLUE CROSS RATE The State Department of Insurance granted Blue Cross a rate increase
INCREASE 24.6 percent for individual subscribers. The increase does not affect
group subscribers, including employees covered through their employer’s
health plans. The rate hikes were granted despite the opposition of
public interest groups such as the American Association of Retired Per-
sons, the New Jersey Public Health Association, the National Organiza-
tion for Women, ACLU, and NAACP. The groups oppose the increase
because they believe many individual subscribers, particularly the elder-
ly and minorities, would not be able to afford higher fees.
Blue Cross described the increase as resulting from changes in Medicare
and in the Uncompensated Care Trust Fund that will saddle Blue Cross
with about 24 percent higher costs in 1990 than in 1989. The rate hike
follows an average increase in individual subscriber rates of 22.2 percent
in 1989.
CUTS REQUIRED IN Former Commissioner of Insurance, Kenneth Merin, ordered two in-
MEDI-GAP PREMIUMS surance companies to lower the rates on Medicare supplemental in-
surance policies for approximately 8,000 policyholders. Merin indicated
that premiums on the Medi-Gap policies of the American Integrity
Insurance Company and United American Insurance Company exceeded
the 35 percent profit margin permitted by the Department. American
Integrity’s monthly premiums are to be reduced from $63.00 to $47.25
and United American’s from $61 to $55.
CONFIDENTIAL AIDS The State Assembly and Senate have passed a bill requiring the names
REPORTING of individuals with AIDS or human immunodeficiency virus (HIV) to
be reported to the State Department of Health on a confidential basis.
The bill also makes confidential the records of individuals with AIDS
or HIV, subjecting persons who unlawfully disclose information to a civil
lawsuit. Information could be disclosed on a confidential basis for the
purposes of medical treatment, research, education, or to the Depart-
ment of Health pursuant to state or federal laws. This legislation goes
beyond existing requirements of reporting AIDS cases by requiring the
reporting of individuals diagnosed with the HIV infection and permitting
the Department of Health to establish six test centers throughout the
state to test patients for HIV.
An interesting development that came out of the final 1990 budget
agreement was the failure of the House and Senate Conference Commit-
tee to include a provision calling for the continuation of a Medicare claim
payment floor. The House version of the budget called for an increase
in the minimum time Medicare intermediaries and carriers could process
claims from 14 days to 16 days while the Senate version called for a 15-
day floor. In the meantime, HCFA issued a notice in the December 11,
1989, Federal Register calling for an extension of the 14-day floor, but
waiving the requirement for the remainder of 1990. HCFA has instructed
Medicare fiscal intermediaries and carriers to process and pay all claims
through September 30, 1990, as soon as possible without regard to the
14-day floor. According to the December 11 notice, the repeal of the
CLAIM PAYMENT
FLOOR LIFTED
164
NEW JERSEY MEDICINE
ATTENDANCE AT MEETINGS OF THE MSNJ BOARD OF TRUSTEES
County and Specialty Societies, Academy of Medicine of New Jersey,
MSNJ Auxiliary, and AMA Delegation
June 1989— December 1989
Atlantic County
June 4 Terry A. Johnston, MD, President
September 17 ... Terry A. Johnston, MD, President
November 19 ... Terry A. Johnston, MD, President
December 17 .... Terry A. Johnston, MD, President
Bergen County
September 17 ... John P. Mudry, MD, First Vice-President
November 19 ... Matis A. Fermaglich, MD
Burlington County
July 16 S. Manzoor Abidi, MD, President-Elect
September 17 ... S. Manzoor Abidi, MD, President-Elect
Charles J. Moloney, MD
November 19 ... S. Manzoor Abidi, MD, President-Elect
December 17 .... S. Manzoor Abidi, MD, President-Elect
Camden County
June 4 Joseph W. Sokolowski, Jr, MD, President
November 19 ... John P. Capelli, MD
Anton P. Kemps, MD
Ardith R. Lane, MD, Executive Director
Donald W. Orth, MD
Lindsay L. Pratt, MD
Joseph W. Sokolowski, Jr, MD, President
Cumberland County
November 19 ... Bernard E. Benson, MD
Essex County
September 17 ... George J. Hill, MD
October 15 William M. Burke, MD
Eli Curi, MD
Joseph P. Fodero, MD
Gloucester County
June 4 Churchill L. Blakey, MD
July 16 Churchill L. Blakey, MD
September 17 ... Churchill L. Blakey, MD
October 15 Churchill L. Blakey, MD
November 19 ... Churchill L. Blakey, MD
George S. Nicoll, MD
December 17 .... Churchill L. Blakey, MD
George S. Nicoll, MD
Hudson County
June 4 Russ C. Camangian, MD, President
Charles L. Cunniff, MD
July 16 Frank J. Primich, MD
September 17 ... Russ C. Camangian, MD, President
Charles L. Cunniff, MD
November 19 ... Russ C. Camangian, MD, President
Charles L. Cunniff, MD
Frank J. Primich, MD
December 17 .... Charles L. Cunniff, MD
Mercer County
June 4 Joey Huddy, Executive Secretary
John G. Winant, Jr, MD, President-Elect
July 16 William H. Hardesty, MD, President
John G. Winant, Jr, MD, President-Elect
September 17 ... William H. Hardesty, MD, President
Linda L. McGhee, Executive Secretary
John G. Winant, Jr, MD, President-Elect
October 15 Linda L. McGhee, Executive Secretary
John G. Winant, Jr, MD, President-Elect
November 19 ... W. Thomas Gutowski, III, MD
Linda L. McGhee, Executive Secretary
Anthony J. Ricketti, MD
Gabriel F. Sciallis, MD
John G. Winant, Jr, MD, President-Elect
December 17 .... William H. Hardesty, MD, President
Linda L. McGhee, Executive Secretary
John G. Winant, Jr, MD, President-Elect
Middlesex County
July 16 Michael P. Ciencewicki, MD,
President-Elect
October 15 Mary Alice Bruno, Executive Secretary
November 19 ... Leticia V. DeCastro, MD, President
Aiden J.M. Doyle, MD
Monmouth County
July 16 Ira M. Rutkow, MD
September 17 ... Lawrence Frieman, MD, President
November 19 ... Noah R. Gilson, MD
December 17 .... Arnold M. Grebler, MD
Ann M. Hughes, MD
Morris County
September 17 ... Michael A. Samach, MD, President
November 19 ... William J. Dowling, Jr, MD, Secretary
December 17 .... Steve Adler, MD, President-Elect
Ocean County
June 4 Nanette Stummer, Executive Director
Passaic County
July 16 Michael H. Bernstein, MD, President
Vincent K. Mclnerney, MD
September 17 ... Michael H. Bernstein, MD, President
October 15 Michael H. Bernstein, MD, President
November 19 ... Michael H. Bernstein, MD, President
December 17 .... Michael H. Bernstein, MD, President
Salem County
June 4 Frank L. Redo, MD, President
October 15 Frank L. Redo, MD, President
Somerset County
September 17 ... John H. Lifland, MD
Sussex County
November 19 ... Bartholomew R. D’Ascoli, MD, President
Paul A. McGee, MD, President-Elect
Union County
June 4 A. Ralph Kristeller, MD
Irene Rosenthal, Executive Director
July 16 A. Ralph Kristeller, MD
Irene Rosenthal, Executive Director
September 17 ... A. Ralph Kristeller, MD
Richard R. Lorber, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
October 15 A. Ralph Kristeller, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
November 19 ... A. Ralph Kristeller, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
December 17 .... A. Ralph Kristeller, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
Warren County
June 4 Robert C. Emery, MD, President
VOL. 87— NUMBER 3 MARCH 1990
165
ATTENDANCE AT MEETINGS OF THE MSNJ BOARD OF TRUSTEES
County and Specialty Societies, Academy of Medicine of New Jersey,
MSNJ Auxiliary, and AMA Delegation
June 1989— December 1989
July 16 Robert C. Emery, MD, President
October 15 Robert C. Emery, MD, President
December 17 .... Robert C. Emery, MD, President
James H. Spillane, MD
New Jersey State Society of Anesthesiologists
June 4 Stanley Bresticker, MD
September 17 ... Stanley Bresticker, MD
December 17 .... Stanley Bresticker, MD
New Jersey Association of Electromyography
and Electrodiagnosis
October 15 Michael Sutula, DO, President
December 17 .... Kutumba S. Pitta, MD, Vice-President
New Jersey Chapter, American College of
Emergency Physicians
June 4 Rudolf E. Schwaeble, MD
July 16 Rudolf E. Schwaeble, MD
September 17 ... Rudolf E. Schwaeble, MD
October 15 Rudolf E. Schwaeble, MD
November 19 ... Rudolf E. Schwaeble, MD
December 17 .... Rudolf E. Schwaeble, MD
New Jersey Academy of Family Physicians
June 4 Sylvia H. Anthony, MD, President-Elect
New Jersey Society of Internal Medicine
September 17 ... Frank J. Malta, MD
October 15 Frank J. Malta, MD
November 19 ... Frank J. Malta, MD
Barry R. Zitomer, MD, President
December 17 .... Frank J. Malta, MD
New Jersey Association of Medical Specialty Societies
June 4 Stanley Bresticker, MD
September 17 ... Stanley Bresticker, MD
December 17 .... Stanley Bresticker, MD
New Jersey Medical Women’s Association
December 17 .... Sandra Samuels, MD, President-Elect
New Jersey Obstetrical and Gynecological Society
November 19 ... John D. Franzoni, MD
December 17 .... John D. Franzoni, MD
Oncology Society of New Jersey
October 15 Alan J. Lippman, MD, President
New Jersey Academy of Ophthalmology and Otolaryngology
September 17 ... Saul M. Tischler, MD, President
October 15 Saul M. Tischler, MD, President
November 19 ... Saul M. Tischler, MD, President
New Jersey Society of Pathologists
September 17 ... Frank Campo, MD
New Jersey Psychiatric Association
November 19 ... Thomas R. Houseknecht, MD
December 17 .... Thomas R. Houseknecht, MD
American College of Surgeons, New Jersey Chapter
September 17 ... Ames L. Filippone, Jr, MD
November 19 ... Ames L. Filippone, Jr, MD
New Jersey Society of Thoracic Surgeons
July 16 Javier Fernandez, MD, Vice-President
September 17 ... Javier Fernandez, MD, Vice-President
October 15 Javier Fernandez, MD, Vice-President
November 19 ... Javier Fernandez, MD, Vice-President
Frederic F. Primich, MD, President
Academy of Medicine of New Jersey
June 4 Sherman Garrison, MD
Charles J. Heitzmann, Executive Director
July 16 Sherman Garrison, MD
September 17 ... Ronnie Davidson, EdD, Associate Director
October 15 Ronnie Davidson, EdD, Associate Director
Charles J. Heitzmann, Executive Director
November 19 ... Sherman Garrison, MD
Charles J. Heitzmann, Executive Director
December 17 .... Ronnie Davidson, EdD, Associate Director
Sherman Garrison, MD
Medical Society of New Jersey Auxiliary
June 4 Dorothy Espinola, Warren County
Medical Auxiliary
September 17 ... Dorothy A. Camangian, President, Hudson
County Medical Society Auxiliary
Jane Lorber, President-Elect
October 15 Sevim Omay, President
November 19 ... Dorothy A. Camangian, President, Hudson
County Medical Society Auxiliary
Vincenza Jasper, Corresponding Secretary,
Passaic County Medical Society Auxiliary
December 17 .... Vincenza Jasper, Corresponding Secretary,
Passaic County Medical Society Auxiliary
Sevim Omay, President
AMA Delegation
Attendance
AMA Delegates
June 4 Ralph J. Fioretti, MD
Palma E. Formica, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Myles C. Morrison, Jr, MD
Edward A. Schauer, MD
Frank Y. Watson, MD
July 16 William J. D’Elia, MD
Palma E. Formica, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Frank Y. Watson, MD
September 17 ... Ralph J. Fioretti, MD
Palma E. Formica, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Myles C. Morrison, Jr, MD
Frank Y. Watson, MD
October 15 Palma E. Formica, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Myles C. Morrison, Jr, MD
Edward A. Schauer, MD
Frank Y. Watson, MD
November 19 ... William J. D’Elia, MD
Frederick W. Durham, MD
166
NEW JERSEY MEDICINE
ATTENDANCE AT MEETINGS OF THE MSNJ BOARD OF TRUSTEES
County and Specialty Societies, Academy of Medicine of New Jersey,
MSNJ Auxiliary, and AMA Delegation
June 1989— December 1989
Palma E. Formica, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Myles C. Morrison, Jr, MD
Edward A. Schauer, MD
Frank Y. Watson, MD
December 17 .... William J. D'Elia, MD
Frederick W. Durham, MD
Ralph J. Fioretti, MD
Palma E. Formica, MD
Henry J. Mineur, MD
Edward A. Schauer, MD
Frank Y. Watson, MD
AMA Alternate Delegates
June 4 Harry M. Carnes, MD
Michael M. Heeg, MD
Paul J. Hirsch, MD
Joseph N. Micale, MD
William E. Ryan, MD
Robert H. Stackpole, MD
Robert J. Weierman, MD
July 16 Harry M. Carnes, MD
Paul J. Hirsch, MD
Donald J. Holtzman, MD
Irving P. Ratner, MD
Carl Restivo, Jr, MD
Joseph A. Riggs, MD
William E. Ryan, MD
Robert H. Stackpole, MD
Robert J. Weierman, MD
September 17 ... Michael M. Heeg, MD
Paul J. Hirsch. MD
Joseph N. Micale, MD
Irving P. Ratner, MD
Carl Restivo, Jr, MD
Joseph A. Riggs, MD
William E. Ryan, MD
Robert H. Stackpole, MD
Robert J. Weierman, MD
October 15 Harry M. Carnes, MD
Paul J. Hirsch, MD
Donald J. Holtzman, MD
Irving P. Ratner, MD
Joseph A. Riggs, MD
William E. Ryan, MD
Robert H. Stackpole, MD
Robert J. Weierman, MD
November 19 ... Harry M. Carnes, MD
Michael M. Heeg, MD
Paul J. Hirsch, MD
Joseph N. Micale, MD
Irving P. Ratner, MD
Joseph A. Riggs, MD
William E. Ryan, MD
Robert H. Stackpole, MD
December 17 .... Harry M. Carnes, MD
Michael M. Heeg, MD
Paul J. Hirsch, MD
Joseph N. Micale, MD
Irving P. Ratner, MD
Carl Restivo, Jr, MD
Joseph A. Riggs, MD
William E. Ryan, MD
Robert H. Stackpole, MD
Robert J. Weierman, MD
Catastrophic Coverage Act has resulted in additional funds being avail-
able for the payment of claims.
MSNJ DELEGATES Karl T. Franzoni, MD, Chairman John S. Madara, MD
TO THE AMA J°seph A. Riggs, MD, Vice-Chairman Henry J. Mineur, MD
Frederick W. Durham, MD Edward A. Schauer, MD
Ralph J. Fioretti, MD Robert H. Stackpole, MD
Palma E. Formica, MD Frank Y. Watson, MD
OPPORTUNITY FOR The impact of drug abuse and AIDS on the nation’s health care system
Ifgy^TH REFORM maY create the opportunity needed by health reform advocates to
achieve “fundamental and comprehensive” health care reform according
to Senator Edward Kennedy (D-MA), chairman of the Senate Human
Resources Committee. Kennedy plans to push for mandatory employer-
paid coverage for the uninsured during the next session of Congress.
While acknowledging that he faces strong opposition, Kennedy believes
that with the support of Senate leadership, he expects a vote on some
aspects of his plan.
HCFA President Bush’s nominee for HCFA administrator, Gail Wilensky, has
NOMINEE j°ineci HCFA, despite not receiving Senate confirmation. Wilensky will
join HCFA on a contract basis. Items on Wilensky’s priority list include
VOL. 87— NUMBER 3 MARCH 1990
167
implementation of Medicare physician payment reform and serving as
vice-chairman on the HHS Task Force on the Uninsured.
VICTORY OVER
ETs
The new Medicare payment reforms will be based on the AMA-sup-
ported resource-based relative value scale (RBRVS). House-Senate con-
ferees approved the RBRVS as the basis for a new physician fee schedule.
But they rejected ETs, the rigid spending caps that would have limited
the amount your reimbursement could rise to a preset target.
NJMS
FELLOWSHIPS
New Jersey Medical School (NJMS) has a unique fellowship program
that allows its students to spend the summer between first and second
year carrying out basic or clinical research in a selected field. This is
one of the largest programs of its kind in the country. The research
usually is done at NJMS under the guidance of a faculty member.
However, the student can arrange to work at other institutions provided
a sponsor is found. The stipend is $1,000 for the eight-week program.
Dr. Erich Hirschberg heads the program at NJMS where a majority of
his work in this area involves raising funds from various sources. The
largest benefactor is the Foundation of the University of Medicine and
Dentistry of New Jersey. Ample support also is provided by the Medical
School Alumni Association with other contributions coming from diverse
sources including federal grants and pharmaceutical companies.
The option to study at outside institutions as well as other aspects of
the program have been threatened. It has been proposed that fewer
students should be selected for a larger stipend and that those students
should work for NJMS faculty only. But the fellowship should be viewed
as an augmented volunteer program rather than summer employment
with the purpose of making money. Last year, 40 percent of the first-
year class participated in the program. This is ample proof that the
current stipend is sufficient. Furthermore, students who are willing to
arrange a fellowship at other hospitals should be rewarded for their
initiative. The cost is no greater for these students while the benefits
are significant; to the student, classmates, and NJMS. The class benefits
by news about research and clinical opportunities at other institutions
while the medical school benefits by widening its reputation. □ Michael
A. Horgan and Eugene Rossitch, Jr, MD
NEW MAMMOGRAPHY
REGULATIONS
New regulations should be redrafted to get rid of an absurd requirement
that prevents many qualified physicians from doing Medicare screening
mammograms, the AMA told the Department of Health and Human
Services (HHS) in a recent letter. MDs board certified before January
1, 1990, would never be able to read a mammogram if they had not before
that date, under the new federal laws. “We do not believe that this was
the intent of the legislation,” said James H. Sammons, MD, AMA
executive vice-president. These regulations should be rewritten to equal-
ize qualification standards regardless of board certification date, the
AMA asserted.
GROUP-TERM LIFE
INSURANCE PLANS
IRS Notice 89-110 has postponed the effective date of regulations con-
cerning employer provided group-term life insurance on the life of a
spouse or dependent of an employee. Previously, the regulations issued
in July 1989 called for gross income inclusion on amounts paid for
insurance coverage for the spouse and/or dependent of the employee.
The notice also provides that employer-provided group term life in-
surance shall be deemed a de minimis fringe benefit, if the insurance
coverage for the spouse or dependent is $2,000 or less. Although this does
provide a safe harbor for employers, the regulations providing for income
168
NEW JERSEY MEDICINE
168
inclusion could become effective once the Internal Revenue Service an-
nounces the effective date for implementation of the rule.
ACTION ON Professional liability continues to be a major concern. The AMA and
PROFESSIONAL over 30 national medical specialty societies have formed the AMA/
LIABILITY SPecialty Society Medical Liability Project (AMA/SSMLP). The AMA/
SSMLP has developed a proposal for an alternative to the jury system
called the “Model Medical Liability and Patient Protection Act.”
RETIREMENT THROUGH A seminar, sponsored by the Medical Society and AMA Investment
SUCCESSFUL MONEY Advisers, Inc., “Gearing Up For Your Retirement Through Successful
MANAGEMENT Money Management,” will be held at Society headquarters on April 4
and April 5. The program, which will be given in its entirety on both
days, runs from 9:30 A.M. to 4:30 P.M. Lunch will be provided as well
as refreshments during the morning and afternoon breaks. You will learn
how to set your personal financial goals, plan for your retirement, lower
your taxes, and develop a financial plan. In addition, the seminar will
cover a variety of investment alternatives such as stocks, bonds, mutual
funds, real estate and much more.
You can sign up for the seminar by calling the Department of Medical
and Insurance Affairs at the Medical Society of New Jersey, 609/
896-1766. Registration deadline is March 28, 1990. Please sign up early
as space is limited to 100 people per seminar; members of MSNJ and
spouses are invited to attend.
SOCIETY OF SURGEONS A member of our Morris County component, Hormoz M. Minoui, MD,
PRESIDENT was elected president of the Society of Surgeons of New Jersey for 1990.
The Society of the Surgeons of New Jersey was established in 1912, and
the statewide society admits only senior surgeons with established
credentials to its membership. Dr. Minoui, who specializes in general
and thoracic surgery, has been on staff at Dover General Hospital Center
since 1963.
AMA PLAN Too many people slip through the cracks in our nation’s health insurance
FOR UNINSURED system. To correct this problem, the AMA developed a multi-pronged
plan that would address the health care needs of all the uninsured and
underinsured. The plan includes a number of state and federal legislative
proposals involving the public and private sector:
• A phased-in requirement that employers provide coverage for all full-
time employees.
• Tax credits for new and small businesses that cover employees.
• An expanded Medicaid program to cover all those living below the
poverty level.
• State risk pools to cover high-risk medically uninsurable persons.
• Full tax deductions for health insurance contributions of self-
employed persons.
• Formation of more multiple employer trusts that allow small em-
ployers to combine risk.
• State indigent care funds.
The AMA has been regularly testifying before Congress to push for these
proposals. Efforts will not stop until the problem of the uninsured is
solved, without interference in the practice of medicine.
FINI “When you betray someone, you also betray yourself.”
VOL. 87— NUMBER 3 MARCH 1990
169
June 11-15, 1990
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LEVOXINE® < Levothyroxine Sodium Tablets, USP) For oral administrate
The following is a brief summary. Before prescribing, please consult package insert
INDICATIONS AND USAGE:
LEVOXINE (L-thyroxine) tablets are indicated as replacement or supplemental therap
for diminished or absent thyroid function, resulting from functional deficiency, primar
atrophy, from partial or complete absence of the gland or from the effects of surger
radiation or antithyroid agents Therapy must be maintained continuously to control th
symptoms of hypothyroidism.
CONTRAINDICATIONS:
L-thyroxine therapy is contraindicated in thyrotoxicosis acute myocardial infarctio
and uncorrected adrenal insufficiency.
WARNINGS:
Drugs with thyroid hormone activity, alone or together with other therapeutic agents have
been used for the treatment of obesity. In euthyroid patients doses within the range of daily
hormonal requirements are ineffective for weight reduction. Larger doses may produce
serious or even life-threatening manifestations of toxicity, particularly when given in as-
sociation with sympathomimetic amines such as those used for anorectic effects
PRECAUTIONS:
Caution must be exercised in the administration of this drug to patients with cardiova;
cular disease. Development of chest pains or other aggravation of the cardiovascular di;
ease requires a reduction of dosage
Patients on thyroid preparations and parents of children on thyroid therapy should b
informed that replacement therapy is to be taken essentially for life They should in
mediately report during the cou rse of therapy any signs or symptoms of thyroid hormon
toxicity, eg, chest pains, increased pulse rate, palpitations, excessive sweating, he<
intolerance, nervousness, or any other unusual event In case of concomitant diabete
mellitus, the daily dosage of antidiabetic medication may need readjustment In case <
concomitant oral anticoagulant therapy, the prothrombin time should be measured frr
quently to determine if the dosage of oral anticoagulants is to be readjusted.
Partial loss of hair may be experienced by children in the first few months of thyroii
therapy, but this is usually a transient phenomenon and later recovery is usually th
rule.
Drug Interactions — In patients with diabetes mellitus, addition of thyroid hormon
therapy may cause an increase in the required dosage of insulin or oral hypoglycemi
agents
Patients stabilized on oral anticoagulants who are found to require thyroid replaci
ment therapy should be watched very closely when therapy is started.
Cholestyramine binds both T4 and T3 in the intestine, thus impairing absorption c
these thyroid hormones Four to five hours should elapse between administration c
cholestyramine and thyroid hormones
Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients without
functioning thyroid gland who are on thyroid replacement therapy may need to increas
their thyroid dose if estrogens or estrogen-containing oral contraceptives are givea
Drug/Laboratory Test Interactions — The following drugs or moieties are known to inte
fere with laboratory tests performed on patients taking thyroid hormone: androgens co
ticosteroids estrogens oral contraceptives containing estrogens iodine-containin
preparations and the numerous preparations containing salicylates
Carcinogenesis, Mutagenesis, And Impairment of Fertility — A reported apparent as
sociation between prolonged thyroid therapy and breast cancer has not been confirmei
No confirmatory long-term studies in animals have been performed to evaluate ca
cinogenic potential, mutagenicity, or impairment of fertility in either males or females
Pregnancy-Category A — The clinical experience to date does not indicate any advers
effect on fetuses when thyroid hormones are administered to pregnant women
Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human mill
Thyroid is not associated with serious adverse reactions and does not have a know
tumorigenic potential. However, caution should be exercised when thyroid is admini:
tered to a nursing woman
Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Routin
determinations of serum (T4) and/or TSH is strongly advised in neonates in view of th
deleterious effects of thyroid deficiency on growth and development
ADVERSE REACTIONS:
Adverse reactions are due to overdosage and are those of induced hyperthyroidism.
OVERDOSAGE — Excessive dosage of thyroid medication may result in symptoms (
hyperthyroidism, which may not appear for one to three weeks after the dosage regime
is begun. The most common signs and symptoms of overdosage are weight loss, palpiti
tion, nervousness, diarrhea or abdominal cramps, sweating tachycardia, cardiac arrh>
thmias, angina pectoris, tremors, headache, insomnia, intolerance to heat and fever,
symptoms of overdosage appear, discontinue medication for several days and reinstitut
treatment at a lower dosage level
Complications as a result of the induced hypermetabolic state may include cardia
failure and death due to arrhythmia or failure
Dosage should be reduced or therapy temporarily discontinued if signs and symptom
of overdosage appear
Treatment of acute massive thyroid hormone overdosage is aimed at reducing ga:
trointestinal absorption of the drugs and counteracting central and peripheral effect
mainly those of increased sympathetic activity. Measures to control fever, hypoglycemia, <
fluid loss should be instituted if needed
DOSAGE FORMS AVAILABLE:
LEVOXINE (L-thyroxine) tablets are supplied as oval, color coded, potency marke
tablets in 11 strengths: 12 'h meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - orangi
50 meg (0.05 mg) - white, 75 meg (0.07 5 mg) - purple, 1 00 meg (0. 1 mg) -yellow, 1 1 2 me
(0.112 mg) - rose, 125 meg (0.125 mg) - brown, 150 meg (0.15 mg) - blue, 175 me
(0. 1 75 mg) - turquoise, 200 meg (0.2 mg) - pink and 300 meg (0.3 mg) - green, in bottles <
100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg an
500 meg injectable (see injectable package insert).
NEW JERSEY MEDICINE
170
PROFESSIONAL
LIABILITY
NO AWARD A hospital employee, bitten by an unrestrained prisoner, was entitled
FOR AIDS-PHOBIA to $35,000 for pain and suffering, a New York trial court ruled. The
employee was bitten on the right forearm while attempting to help
subdue the prisoner. The court awarded the employee $35,000 for pain
and suffering but refused to award him compensation for the AIDS-
phobia he allegedly suffered. The court said police officers were negligent
in not being in the same room as the unrestrained prisoner. The em-
ployee was tested for AIDS three times with negative results each time.
There was no evidence that the prisoner had AIDS, the court said.
(Reprinted with permission from The Citation, American Medical As-
sociation, Volume 60, November 1, 1989.)
NEGLIGENCE An HMO was vicariously liable for the negligence of a cardiologist
Qp ^ NON-HMO brought in as a consultant by an HMO physician, a federal appellate
CONSULTING PHYSICIAN court ^or t^ie District of Columbia ruled.
The patient, a 48-year-old man, was a subscriber of the HMO through
his employer. In March 1983, the patient was treated at the HMO for
abdominal pain. On May 6, 1983, the patient spoke with an HMO nurse
about continual stomach pain. On May 12, the patient called the HMO
about a 45-minute episode of chest pain radiating into his left shoulder.
The patient was sent to a hospital emergency room; an EKG was done.
The EKG was interpreted as having nonspecific S-T wave changes. An
HMO physician admitted the patient to the hospital’s coronary care unit
and brought in a non-HMO cardiologist to examine the patient.
After reviewing the available information, the cardiologist determined
that the patient probably did not have a heart attack. The cardiologist
scheduled tests and found the patient’s MUGA test results to be normal
but the patient’s stress EKG results were abnormal. Nevertheless, the
cardiologist concluded it was unlikely the patient had coronary heart
disease and did not order more tests or restrict the patient’s activities.
In the four nights following the MUGA test, the patient complained to
an HMO physician of profuse night sweats. After reviewing the patient’s
medical record, which did not yet include the results of the abnormal
stress EKG, an HMO physician told the patient that the night sweats
were not cardiac related.
On June 19, 1983, the patient began to sweat heavily and became ex-
hausted after mowing his lawn and doing some housework. The next day
he began to vomit and was very weak and tired. The patient’s wife called
the HMO nurse; the nurse said he would have to sweat out his condition.
When the wife returned, she found the patient gasping for air. The
patient stopped breathing before the rescue squad arrived and he died
in the ambulance on the way to the hospital.
The patient’s wife, as personal representative of the patient’s estate,
sued under the District of Columbia’s survival statute and claimed that
the HMO physician had negligently failed to diagnose and treat the
patient’s latent coronary artery disease.
VOL. 87— NUMBER 3 MARCH 1990
173
PROFESSIONAL LIABILITY
The jury returned an $825,000 lump sum verdict in favor of the wife,
as the personal representative of the patient’s estate. The HMO ap-
pealed on several issues. First, the HMO contended that it had not
breached its contractual duty to provide adequate health care and was
not vicariously liable for the negligence of the consulting cardiologist
because he is an independent contractor. The federal appellate court
disposed of the HMO’s first argument by stating that “the record is
replete with . . . evidence” that the HMO breached its contractual duty.
Secondly, the appellate court held that under the law of the District of
Columbia, the HMO was responsible for the negligence of the
cardiologist, despite his status as an independent contractor. The court
pointed out that the cardiologist was brought in on the patient’s case
by an HMO physician. Therefore, the HMO selected him. Further, the
HMO had some ability to control the cardiologist in that he reported
to the patient’s primary physician, an HMO physician. Finally, the
cardiologist’s actions were part of the regular business of the HMO.
The federal appellate court explained that while the courts in the Dis-
trict of Columbia had not addressed the issue of when an independent
contractor is an apparent or ostensible agent, there is a decision by the
federal district court for the District of Columbia holding that an em-
ployer is not responsible for the acts of an independent contractor when
the independent contractor is acting on his own initiative and without
direction or control of the employer. The appellate court opined that in
the case at issue, the cardiologist acted neither on his own initiative nor
independently of the HMO physician. Actually, the cardiologist “only
made recommendation to the [HMO] doctor,” the court noted.
The appellate court also referred to an opinion from Maryland’s highest
court that held a hospital was responsible for its emergency room phy-
sicians even though they were independent contractors because “pa-
tients who came to the emergency room reasonably expected — and were
not disabused of the notion — that the doctors in the emergency room
were hospital employees.” By analogy, according to the court, the
cardiologist was brought in by the HMO to examine the patient who
had every reason to believe the cardiologist was the HMO’s agent.
The HMO also raised questions on appeal concerning the calculation
of the amount of damages. The court found that there was no need for
an expert to testify as to the calculation of the patient’s lost future wages
because there was sufficient testimony by his employer regarding his
employment history. The court held that expert testimony was necessary
to guide the jury on questions of inflation and discounting to present
value. The court held that the HMO was entitled to a jury instruction
that any award would not be subject to taxes, because this instruction
would help the jury in calculating the patient’s lost earnings.
Based on these findings, the appellate court reversed in part and re-
manded the case for a new trial only on the amount of damages.
COMMENT It is likely that more personal injury suits brought against HMO physi-
cians also will name the HMO under the theory of respondeat superior,
even if the physicians are independent contractors. It is not at all un-
usual for a hospital to be found liable for the negligence of physicians
on its medical staff for various reasons — ostensible agency, negligent
credentialing, etc. The same theories apply to HMOs and their rela-
tionships with physicians who are independent contractors. (Terrie A.
Rymer, JD, staff attorney, Health Law Division, AMA, reprinted with
permission from The Citation, AMA, Vol. 60, November 1, 1989.)
174
NEW JERSEY MEDICINE
PRESIDENT’S
PAGE
YOUR PROFESSIONAL One of the most important, and one of the finest, actions of the Medical
LIABILITY INSURANCE Society of New Jersey on your behalf was the formation of an insurance
company to provide professional liability coverage for the physicians of
New Jersey. This came at the height of the “malpractice crisis” and at
a time when professional liability coverage might not have otherwise
been available in New Jersey.
At that time, the Medical Society of New Jersey founded the Medical
Inter-Insurance Exchange of New Jersey (MIIENJ), a reciprocal com-
pany owned by its insureds. This was to be an insurance company that
would serve its insured physicians, in a manner otherwise unavailable
to our members. It has fulfilled this goal admirably.
Because New Jersey law requires that a reciprocal insurance company
be managed by an “attorney-in-fact,” the Medical Society of New Jersey
also formed the New Jersey State Medical Underwriters, Inc. (NJSMU)
to “service” and provide active management for the Medical Inter-
Insurance Exchange of New Jersey. NJSMU is wholly owned by the
Medical Society of New Jersey and its membership. The Board of
Trustees of the Medical Society of New Jersey has the responsibility to
ensure that the board of directors and management of the New Jersey
State Medical Underwriters Inc. continues to be responsible to, and
responsive to, the Medical Society of New Jersey and its membership.
We take this obligation very seriously.
In recognition of this responsibility, your Board of Trustees recently has
enlarged the board of directors of NJSMU, to broaden representation.
New members are Drs. Harry Carnes, Paul Hirsch, Fred Palace, Joseph
Riggs, and Herman Robinson.
The Medical Inter-Insurance Exchange of New Jersey, and the New
Jersey State Medical Underwriters, Inc. are very important to you, and
very important to your officers and trustees. We expect through
enhanced management and participation to continue to meet all your
professional liability insurance needs.
HONORS TO Two members of the leadership of the Medical Society of New Jersey
DR. FIORETTI & recently have been selected to receive prestigious awards.
DR. FARES Dr. Ralph J. Fioretti, of Bergen County, past-president of this Society
and a member of our AMA Delegation, was selected to be the recipient
of the New Jersey Doctor of the Year Award, of the New Jersey Academy
of Family Practice. Dr. Fioretti has been one of our most beloved and
respected leaders.
Dr. Louis G. Fares, of Mercer County, MSNJ judicial councilor from
the Third District, has been honored by the Mercer Unit of the American
Cancer Society, at the Annual Joyce McDade Memorial Ball, as “an
outstanding citizen ... a fine physician . . . and a dedicated volunteer
in the fight to control cancer.”
We are very proud of Dr. Fioretti and Dr. Fares, and of the many
VOL. 87— NUMBER 3 MARCH 1990
177
PRESIDENT’S PAGE
members of the Medical Society of New Jersey who serve their pro-
fession, serve their communities, and serve the citizens of New Jersey.
CAPITALISM VERSUS On the last day of 1989, economist Milton Friedman wrote an article
S^)(gQ^LISM *n New York Times summarizing some recent trends. He began by
noting that “socialism is a failure,” wherever it has been tried, that
“capitalism is a success,” and that free private markets have demon-
strated their effectiveness. He then goes on to state, ironically, that many
people have somehow drawn the conclusion that the United States needs
more socialism.
Mr. Friedman describes socialism as government ownership and control.
He notes that those areas of our economy that are controlled by govern-
ment are our most technologically backward areas. He states that these
areas are typified by waste, fraud, and inefficiency.
Yet, he notes that despite this, one of the most persistent complaints
seems to be that “government should be doing more . . . .”
In his article, Mr. Friedman does not discuss medical care; but the lesson
is clear. Increased taxes and increased government participation never
are the solution to a problem, and never have created an improved
product or an improved service. It is the task of the Medical Society
of New Jersey to continue to represent our profession, our patients, and
our citizens, preventing or minimizing government incursions into medi-
cine, and maintaining the unique quality of care in this country.
SPECIAL ISSUE This issue of NEW JERSEY MEDICINE is devoted to the history of
women in medicine. We are proud of the role women have played in the
New Jersey medical community, and we are proud of the expanding role
they will play in the future. □
178
NEW JERSEY MEDICINE
EDITOR’S
DESK
HIPPOCRATES’ I shall make him a helper for him.” Thus, Adam’s rib was used to create
RIB Eve-a woman out of a man — as a companion and partner, to be “bone
of my bones” and “flesh of my flesh,” and for a man and wife to become
one flesh.
Through the years, women have been considered more as handmaidens,
servants, or attendants, subservient or subordinate to the male, rather
than as equal partners. Today’s battles for equality have narrowed the
gap dramatically. Nowhere is this seen more clearly than in American
medicine, where women now represent about one-third of enrollments
to medical school, and where women are accepted in diverse fields of
practice, including all the surgical disciplines. The progress has been
slow. This month’s feature article dramatizes the pioneering efforts of
American women physicians in the 19th and early 20th centuries,
emphasizing the involvement of women with New Jersey medical so-
cieties. It is being published now to coincide with the observance of
National Women’s History Month, to be punctuated in New Jersey by
a conference and fair at Trenton State College on March 16, 1990.
The history of women in medicine is the history of medicine itself.
Women in the 5th century BC were performing mastectomies and
caesarean sections. Women founded hospitals in the 4th and 5th cen-
turies AD for the poor and needy and served patients therein, usually
without fees. In medieval times, many women graduates of the school
in Salerno were among the most influential physicians of the day. The
doors began to close on female practitioners when the study of medicine
began to rest more firmly on scientific inquiry; few women had access
to formal education. It has taken much effort, attended by slow progress,
in the 19th and 20th centuries to open these scholarly doors.
Elizabeth Blackwell, despite all the publicity given her, was not the first
woman physician in the United States; she was the first female graduate
of a recognized American medical school. (Interestingly, her namesake,
another Elizabeth Blackwell, was a renowned herbalist and physician
in the United Kingdom in the 18th century.) The early colonies had
“doctoresses,” but they faded from view in the 18th century from societal
pressure and the need for medical education to be obtained abroad, an
enterprise enjoyed almost exclusively by men of means. In the early 19th
century, an individual could become a licensed practitioner either by
apprenticeship and examination or by graduation from one of the few
medical schools then extant. Among the former group were Harriet Hunt
(1805-1875) and her sister, Sarah, who practiced in Boston as early as
1835 and who developed a large practice. Harriet should be remembered
and applauded by all of us for her tireless efforts to obtain equal treat-
ment for women by medical schools and by society; she was, indeed,
the “first” American woman physician.
We are pleased by the strides made by women in medicine. In New
Jersey, we have had women as presidents of county societies and as
president and chairman of the Board of the Medical Society of New
VOL. 87— NUMBER 3 MARCH 1990
181
EDITOR’S DESK
Emma Weeks (seated with book) in the anatomy laboratory of the Woman's Medical College of Pennsylvania. Dr. Weeks
was a graduate of the 1 892 class, and was the first woman physician of the Burlington County Medical Society. (Archives
and Special Collections on Women in Medicine, Medical College of Pennsylvania. Published with permission.)
Jersey. The American Medical Association (AMA) has a practicing
female physician as an elected member of its Board of Trustees.
Nevertheless, women physicians are reluctant to commit themselves to
epicenic medical organizations. The American Medical Women’s As-
sociation (AMWA) is a fine organization, but it can speak only for
women and, like it or not, it carries little clout outside its ranks. Mem-
bers of a Hibernian group or the Veterans of Foreign Wars can find
participation rewarding, but they must exercise their voting privileges
to ensure representation. Similarly, members of AMWA and unaffiliated
women physicians would serve themselves well, as they would their
colleagues and their patients, were they to emulate the New Jersey
pioneers limned in Ms. Hutner’s report and join county and state medi-
cal societies and the AMA. It is time for women to reflect the collegiality
of today’s medical schools. □
Woman is woman’s natural ally.
Euripides (5th century B.C.)
But man is no longer the enemy.
Slobodien (1990 A.D.)
182
NEW JERSEY MEDICINE
BOOK
REVIEWS
Murray Schwartz, DDS. Oradell, NJ, Medical Economics Books, 1989.
When one first peruses this 300-page text on physical office acquisition
and/or construction, an immediate reaction is that this book presents
more information than one possibly could use. However, as a physician
who has been through this process several times, and as a medical
educator who realizes how little curricular time is devoted to this topic
in the course of undergraduate and graduate medical education, I believe
this text could be invaluable to the practicing physician.
Most medical educators have little or no concern about their clinical
office, given that most of them practice in locations on a hospital cam-
pus, or in large multispeciality groups administered by a faculty practice
plan. On the other hand, private practitioners, who represent the bulk
of medical practice in this country, generally do so in private offices they
obtain and maintain with little formal guidance.
Dr. Schwartz’s book is comprehensive and succinct. I found the author’s
advice to be accurate, well thought out, and up to the minute. Yet, he
presents, in a very factual fashion, some issues that, upon reflection, are
his own conclusions and may be subject to considerable debate among
other professionals. However, he consistently and appropriately advises
the reader to seek consultation with experts in the various applicable
fields, and he gives the reader a very good sense of what one can expect
from such consultations. This book is must reading for anyone antici-
pating constructing an office building. And, it is suggested reading for
anyone who has to deal with the issue of a professional office even if
it is only in rental space. □ Joseph A. Lieberman, III, MD
FUNDAMENTAL William E. Paul. New York, NY, Raven Press, 1989. This textbook fully
IMMUNOLOGY, fulfills the title and is a must for any serious immunologist. The text
SECOND EDITION Provlcles a background of information in immunology; it has been written
by major experts in the various areas of immunology and includes a
separate chapter on critical techniques including the famous FACS (flu-
orescent activated cell sorting) and long-term culture of immunocompe-
tent cells that are critical for any serious immunologic laboratory. In
addition, there are separate sections of the text with several chapters
included in each, covering areas of mechanisms of immunity, e.g. com-
plement, phagocytosis, cytotoxic T-lymphocytes, and natural killer cells,
and cytotoxic macrophages. Several sections are devoted to the regu-
lation of the immune response as well as lymphocyte activation,
proliferation, and differentiation. One of the most well-designed chapters
is on autoimmunity and autoimmune diseases, in which areas of human
autoimmune diseases are described by their basic immunological
pathogenesis and then compared to the most appropriate animal models
which reflect similar process.
I highly recommend this book to any serious basic immunologist or
clinical immunologist; it is a delightful and easy reading text and can
function as an adjunct to Samter’s text on Immunologic Diseases and
Middleton’s Allergy: Principles and Practice. □ Leonard Bielory, MD
DESIGNING AND
BUILDING YOUR
PROFESSIONAL OFFICE
VOL. 87— NUMBER 3 MARCH 1990
185
For treatment of diabetes:
REPLACE
Human Insulin
^wt
With Human Insulin
Any change of insulin should
be made cautiously and only
under medical supervision.
Humulin®
human insulin
[recombinant DNA origin]
Leadership
In Diabetes Care
© 1989, ELI LILLY AND COMPANY HI-2914-B 949334
186
NEW JERSEY MEDICINE
Grace Under Pressure
The First Women To Join the
County Medical Societies of New Jersey
GERALDINE R. HUTNER, MA
The women were as different as night and day.
Yet, they had one common goal: to succeed
as physicians. These were the women who
broke the barrier to become the first women mem-
bers of the New Jersey county medical societies.
Why did these women want to become physicians?
In the late 1800s and early 1900s, this choice of a
profession was questionable: “It may be said by
some people that, even if women are competent to
become good doctors, they will lose more than they
gain. People will ask concerning the woman doctor,
not, Is she capable? but, Is this fearfully capable
person nice? Will she not upset our ideals of woman-
hood and the relations between the sexes? Can a
woman-doctor be a womanly, lovable person?”1
Yet, the women who desired to be physicians were
willing to deal with a social climate that was far from
warm: they endured social stigma, personal hard-
ships, and sexual discrimination in order to fulfill
their dreams.
But there were voices willing to concede that
women would be able to be physicians — and good
ones. The Woman’s Book, a two-volume, how-to
book for women in the late 1800s, ended its section
on occupations for women in medicine on a positive
note: “Whether women will ever do as much or as
remarkable, work in this field [medicine] as men,
has but little to do with the question. The law of
supply and demand may be trusted here as else-
where, and if women doctors do not meet a real need
Ms. Hutner is executive editor of NEW JERSEY MEDI-
CINE. Requests for reprints may be addressed to MSNJ,
Two Princess Road, Lawrenceville, NJ 08648.
they will die out. At present, it is certain that a
definite demand for their services does exist. And as
an injustice is not small because it concerns a small
number, if a single woman desires to consult a doctor
of her own sex, and if one other woman desires to
qualify herself to be that doctor, no obstacles ought
to be placed in the way. No one has the right to
decide what is or is not another person’s proper
sphere. The proper spheie for all human beings is
the largest and the highest they are able to attain
to, and what this is cannot be ascertained without
complete liberty of choice.”1
MEDICAL EDUCATION FOR WOMEN
Dr. Joseph S. Longshore was a driving force in the
establishment of a Philadelphia medical school for
women, as his sister and sister-in-law were both
serving as apprentices in his clinic. Consequently, in
1850, the Female Medical College of Pennsylvania
was opened in the back of a rented house on Arch
Street in Philadelphia2 with a faculty of six physi-
cians and 40 students.3 After the Civil War, the
school was reopened and renamed the Woman’s
Medical College of Pennsylvania under the director-
ship of Ann Preston, MD. Because medical educa-
tion of women was still walking a fine line, the Col-
lege “did offer a superior course, often initiating
groundbreaking reforms. Operating under intense
public scrutiny, professors (male and female) were
careful to teach only regular therapeutics.”2 With
lectures and clinical work, students also were given
practical training, as the College had a dispensary
and hospital, opened in 1858 and 1861, respectively.
Requirements for graduation included the study of
VOL. 87— NUMBER 3 MARCH 1990
187
Figure 1. Elizabeth Blackwell, MD, was the first woman to receive a medical degree in the United States.
(Published with permission. © Archives and Special Collections on Women in Medicine, The Medical College
of Pennsylvania.)
medicine for three years, six months service in a
recognized hospital, and two lecture courses on
chemistry and toxicology, anatomy, materia medica
and general therapeutics, physiology and hygiene,
principles and practice of medicine, principles and
practice of surgery, and obstetrics and disease of
women and children.2
Applicants were to be between the ages of 20 and
35. Fees for the Medical College included a matricu-
lation ticket for $5, professors’ tickets for $105,
practical anatomy for $10, and the graduation fee for
$30, with the whole cost for two or more courses of
lectures and graduation for $265. There was a final
examination and a senior thesis to be completed
before the doctor of medicine degree was awarded
to the graduate. For 120 years, the College continued
as a medical school for women.
The Women’s Medical College of the New York
Infirmary was founded by Elizabeth Blackwell and
her sister Emily in 1868 because, as Elizabeth put
it, “The practice of medicine by women no longer
is a doubtful, but a settled thing. But there is not
in the whole extent of our country a single medical
school where women can obtain a good medical
education.”4
Elizabeth Blackwell was the first woman to re-
ceive a medical degree in the United States; she
obtained her diploma from Geneva College of Medi-
cine in upstate New York under unusual circum-
stances. After studying with Dr. Joseph Warrington
of Philadelphia, Elizabeth applied for admission to
Geneva, an all-male school. The Dean felt the stu-
dents would not tolerate the presence of a woman
and so he let them vote on Elizabeth’s application.
To his surprise, the student body voted to accept the
request, stating “that the application of Elizabeth
Blackwell to become a member of our class meets
our entire approbation; and in extending our unani-
mous invitation we pledge ourselves that no conduct
of ours shall cause her to regret her attendance at
this institution.”5 Although the students did not live
up to this pledge, Elizabeth persisted and on Janu-
ary 23, 1849, she duly received a doctor of medicine
degree.
188
NEW JERSEY MEDICINE
Table. Women members of the county societies of New Jersey.
Name
Year
Birth/Death
Medical School/Graduation
County
Membership
Chard, Marie
1868-1938
Women’s Medical College/
New York Infirmary— 1895
Ocean
1908-1924
Clark, Alice
1903-
University of Buffalo— 1933
Hunterdon
1936-1966
Clark, Emma
1866-1923
Syracuse University— 1902
Morris
1906-1924
Clement, Ruth
1848-1925
Woman’s Medical College of PA— 1889
Gloucester
1915-1925
De Hart, Florence
1871-1906
Women’s Medical College/
New York Infirmary— 1893
Hudson
1899-1906
Dunlap, Mary
1853-?
Woman’s Medical College of PA— 1886
Cumberland
1901-1909
Galt-Simmons, Eleanor
1854-1909
Woman’s Medical College of PA— 1879
Union
1886-1895
Gaston, Mary
1855-1956
Woman’s Medical College of PA— 1888
Somerset
1891-1911
Grier, S. Mabel
1880-1969
Johns Hopkins— 1905
Mercer
1908-1909
Hallowell, Rebecca
1830-1909
Woman’s Medical College of PA— 1878
Atlantic
1883-1891
Haines, Eleanor
1846-1924
Woman’s Medical College of PA— 1871
Essex
1876-1924
Hand, Anna
1849-1921
Woman’s Medical College of PA— 1890
Cape May
1901-1915
Marsh, Caroline
1863-1922
Woman’s Medical College of PA— 1890
Middlesex
1892-1894
Mackintosh, Sarah
1836-1903
Women’s Medical College/
New York Infirmary— 1872
Passaic
1872-1887
Monmouth
1888-1903
Presley, Sophia
1834-1909
Woman’s Medical College of PA— 1879
Camden
1890-1904
Sheffield, Doreen
1907-1961
Manitoba Medical School— 1929
Warren
1950-1962
Smith, Ellen
1866-1920
Woman’s Medical College of PA— 1892
Salem
1916-1920
Stewart, Katherine
1911-
Cincinnati Medical School— 1935
Sussex
1944-1950
Van Horne, Caroline
1862-1914
Woman’s Medical College of PA— 1894
Bergen
1899-1914
Weeks-Metzer, Emma
1870-1964
Woman’s Medical College of PA— 1893
Burlington
1896-1950
VOL. 87— NUMBER 3 MARCH 1990
189
Dr. Blackwell realized the need for a hospital in
which women physicians could practice, and so with
her physician-sister Emily, she helped to raise
enough funds by 1857 to establish the New York
Infirmary for Women and Children in New York
City (now Beekman Hospital); 11 years later, with
the approval of colleagues and workers, Elizabeth
and Emily Blackwell fought to have the Infirmary’s
charter amended to allow it “to grant and confer the
title of Doctor of Medicine.”4
In November 1868, the Women’s Medical College
of the New York Infirmary opened with a class of
17 students, 11 faculty members, and an 8-member
Board of Examiners. The records state: “A good
general education was required for admission. Before
receiving their diplomas, the candidates were asked
to present a certificate from a clergyman, physician,
or other responsible person, testifying to their moral
character. A full year’s course of lectures cost $105
plus $5 for the demonstrator’s fee. Graduation fee
was $30 and a matriculation ticket cost $5. 4 During
the first year, students studied anatomy, physiology,
materia medica, and chemistry; and there was prac-
tical work in pharmacy and in the anatomy rooms.
In the second year, there was additional class work
in medicine, surgery, hygiene, and obstetrics. Small
group bedside instruction, as well as a residency at
the school’s Infirmary, also were available to second-
year students. During their third year, students per-
formed practical work and were expected to make
case reports for their professors. All students
prepared final thesis papers for their degrees.
The school had many eminent alumnae and lasted
until 1899, closing only when coeducation for medi-
cine seemed assured.
Between 1850 and 1895, there were 19 additional
medical schools for women, including Johns
Hopkins, Baltimore; Syracuse University, New
York; University of Michigan; and New England
Female Medical College, Boston.
MEDICAL SOCIETIES
The need to join a medical society was as impor-
tant in the 19th and the early 20th centuries as it
is today. “It was in medical societies that physicians
could meet to exchange information on medical
ideas, techniques, and innovations. American medi-
cal societies were involved with medical licensing,
setting professional standards, establishing fees,
controlling schedules, and generally standardizing
their profession. Through medical societies, physi-
cians received case referrals and recommendations
to hospital and other professional appointments. In-
deed by the late 19th century, medical society mem-
bership was a virtual prerequisite for most hospital
affiliations. . . . Membership in medical societies ac-
corded its members status, economic, and profes-
sional advantages, and consciously sought to estab-
lish inside and outside groups within the pro-
fession.”2 In addition, membership in medical
societies separated qualified physicians from others,
and this brought women an unspoken acceptance
into the profession.2
Physician applicants were nominated by col-
leagues; the executive and credentials committees
voted on the application after forms were filed and
letters of recommendation were completed. After
physicians were elected to the county society, names
would be submitted to the state society; at the an-
nual meeting, usually held in the spring, the can-
didates would be placed into nomination, and if no
objections were voiced, the candidates were elected
into the state society.
By the 1870s, women physicians were accepted
into state and county medical societies. Montgom-
ery County Medical Society in Norristown, Penn-
sylvania, noted in May 1870, “Doctress Anna
Lukens was elected a member,”7 and the April 9,
1872, transactions of the State Medical Society of
Kansas state, “The Board of Censors reported
favorably on the credentials of Dr. Francena R.
Porter” and after she signed the constitution, she
became a member of the Society.8 On October 7,
1872, six months later, Sarah F. Mackintosh, MD,
became the first woman member of a New Jersey
county society and in June 1873, the first member
of the Medical Society of New Jersey. In 1876, S.
Stevenson signed the roll call of the Illinois Medical
Society, keeping her sex a secret (Sarah Hackett).
Rhode Island and Michigan accepted women mem-
bers in 1877, and by 1881, 17 state medical societies
admitted women, including the Massachusetts
Medical Society that admitted Dr. Emma L. Call
in 1884. The American Medical Association ad-
mitted its first woman member in 1915.
By 1900, women physicians composed almost 5
percent of the medical profession — about 7,000 phy-
sicians.
The following pages contain biographies (Table)
of the women who made history in New Jersey.
Many of the details of the lives of these women are
buried with them, their family, and their friends.
Personal feelings and emotions most likely will re-
main an enigma. What made them attend medical
school and become physicians we may never know.
It would appear, though, that these women were
feminists in their own right, challenging the mores
of the times. These women were active supporters
of family and the medical community, combining
the traditional roles expected of them and adding a
nontraditional role — as physician. Yet, these women
joined their county societies and the State Society,
the Medical Society of New Jersey, and paved the
way for the women physicians after them. □
190
NEW JERSEY MEDICINE
Rebecca Hallowell
Atlantic County
When the railways were completed in 1854, the
communities of southern New Jersey became land-
marks as famous resort areas. The sea air was found
to be a “natural medicine” and the entire Atlantic
County was reborn.
In 1874, physicians in Atlantic County applied to
the State Society for a charter to organize a county
component. The request was approved, but it was
not until June 7, 1880, that Atlantic County began
to function regularly.9
The membership elected its first president in
1881, Job B. Somers, MD, and seven members at-
tended the first meeting of the Atlantic County
Medical Society. In 1882, the County sent its first
representatives to the MSNJ Annual Meeting; by
this time there were 11 members (with 541 members
in the State Society) and Boardman Reed, MD, was
the president.
As Atlantic County grew, so did the Medical So-
ciety. By 1883, the Society boasted 17 members, and
the State Society was composed of 580 members.
The Society’s roster for this year noted that Edward
North, MD, was the president, and that Rebecca
Cooper Hallowell, MD, was a new member.9 The
Society’s annual report made no special mention of
Dr. Hallowell’s entry into the Society, as the first
woman member of the group.
Born in 1830, Rebecca Hallowell graduated with
the class of 1878 from the Woman’s Medical College
of Pennsylvania. Upon receiving her New Jersey
license the following year, she was listed as a regular
physician in Atlantic City.910
In the welcoming address for the Medical Society
of New Jersey Annual Meeting in 1883, Dr. Reed
noted the tremendous growth of Atlantic City, with
two railroads, gas works, electric lights, an ocean
pier, hotels, boarding houses, water works, garbage
collection, cesspools with a sewage system in the
making.9 It was in this seaside world that Dr. Hal-
lowell lived. The minutes and recording secretary
reports make no mention of her activities, except to
say she was a physician and member of the county
society.
Figure 2. In 1883, Dr. Rebecca Hallowell became the first
woman member of the Atlantic County Medical Society.
(Published with permission. © Archives and Special Col-
lections on Woman in Medicine, The Medical College of
Pennsylvania.)
During her years in Atlantic City, Dr. Hallowell
entered into a partnership with six other women:
Mary A. Riddle, Julia M. French, Huldah A. Carter,
Caroline E. Riddle, Julia P. Brown, and Mrs. Henry
Mosebach. They formed a company on July 18, 1883,
called the Chelsea Beach Company, a real estate
investment company. Little is known of the success
of the company, but Dr. Hallowell retained her own-
ership in this venture until 1888.”
Dr. Hallowell was listed in the membership rolls
until 1891 when her name disappears from the
roster. Around this time. Dr. Hallowell accepted a
position as a medical missionary offered her by the
Women’s Matronal Indian Association; she was to
help to establish a hospital at Adun Colentz, San
Diego County, California. In early 1907, Dr. Hal-
lowell retired from the active practice of medicine
and returned to her home in Haddonfield. She died
of heart disease at home on October 12, 1909, at the
age of 79. 6 □
VOL. 87— NUMBER 3 MARCH 1990
193
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194
NEW JERSEY MEDICINE
Caroline Van Horne
Bergen County
On December 14, 1818, 11 physicians met to or-
ganize the fifth county medical society in New Jer-
sey. Due to the frontier-like setting of this communi-
ty, the group dissolved and was reorganized in 1836.
This new attempt lasted just a short time, with the
members gathering for only one meeting. Finally, on
Sunday, February 28 1854, the physicians in Bergen
County met in Hackensack to re-establish their
medical society, under the direction of president
William H. Day, MD. The group remained some-
what inactive until 1858, when the members estab-
lished regular meetings and scientific exchanges.12, 13
One of their major accomplishments was the open-
ing of Englewood Hospital on May 1, 1890. Nine
years later, the Bergen County Medical Society
elected its first woman member, Caroline Helen
Van Horne, MD.9
The Van Horne family can be traced to immigrant
ancestors, Christian Barrentsen Van Hoorne and
Jannetje Jans who settled in New York City before
1657. Descendant David C. Van Horn (1830-1896)
married Alice Jane Branum (1836-1909) on Decem-
ber 4, 1856. (Originally from Schraalenburgh, New
Jersey, David moved to Wisconsin and in 1860 he
returned to Closter, Bergen County.) David and
Alice had two children: Byron Garret, born on Octo-
ber 2, 1857, in Beaver Dam, Wisconsin, and Caroline
Helen, born on April 18, 1862, in Closter.14
The Van Horne family lived at Schraalenburgh
Farm, and Carrie, as she was better known, and
Byron were educated in the local public schools in
Closter; later, Byron went to Hasbrooks Institute in
Jersey City, and Carrie was sent to private schools
in Englewood. Byron and Carrie both entered medi-
cal school in 1892: Byron at the University of Penn-
sylvania (graduating in 1896) and Carrie at the
Woman’s Medical College of Pennsylvania. Carrie
graduated with the class of 1894. 14, 15 During their
years of medical training, Byron worked to cover the
costs of his and Carrie’s medical schooling.16 For one
year, she worked at the Woman’s Hospital.
Dr. Carrie Van Horne was licensed in Penn-
sylvania and New Jersey in 1895. 15 Carrie began her
private practice of medicine with her brother at 151
Englewood Avenue, Englewood, in 1897. To dis-
tinguish between the two physicians, Carrie’s
brother was called Dr. Van Horne and she was
known as Dr. Carrie.16 A general physician, Dr. Car-
rie was awarded privileges at Englewood Hospital
and served as a member of the Hospital Board. In
Figure 3. Dr. Caroline Van Horne and her brother, Dr.
Byron Van Horne, practiced in Bergen County in the early
1 900s. Dr. Carrie, as she was known, was the first woman
member of that county society. (Courtesy of George
Willis, Bergen County Medical Society.)
VOL. 87— NUMBER 3 MARCH 1990
195
Figure 4. Physican-members of the 1902 Bergen County Medical
Society.
addition, she was the medical advisor of the
Englewood Day Nursery.6' 17
Three years after moving to Englewood, Dr. Carrie
joined the Bergen County Medical Society. In 1900,
there were 36 members of the County Society and
898 members of the State Society.9 Minutes for the
quarterly society meetings were reported regularly in
The Journal. Dr. Carrie’s name never was mentioned
as a speaker or a delegate to the State Society meet-
ings; the reporter did note, however, that meetings
were well attended by almost all members. (Byron
joined the Bergen County Medical Society in 1902,
and remained a member of the Society until his
death on November 20, 1922, at the age of 64.)
Group photographs were taken of the Bergen
County Medical Society in 1902 and 1912; Dr. Carrie
was present at both sittings. The black-and-white
photographs show a light-haired, serious young
physician, surrounded by male colleagues.13 Notes
from the County Society state: “Her cheerful face
combined with her confident manner in the sick
room contributed largely to her professional suc-
cess.” That she won favor and able standing is
shown by the fact of her becoming a member of the
Bergen County Medical Society and of the
Englewood Hospital Medical Board. Her interest in
matters apart from her calling proper appeared in
her active connection with the Women’s Club of
Englewood, with the Bergen County Historical So- i
ciety, and with the societies of the Presbyterian
Church of Englewood.17
Dr. Carrie Van Horne was one of 70 members of
the Bergen County Medical Society when she died
at home on February 3, 1914, after a six months’
illness of myocarditis; she was 51. It was reported
that nearing death, medical efforts were made to
revive Dr. Carrie; she came to enough to say,
“Please do not try any more. It is so beautiful and
peaceful.”1516 Her will, written in July 1912 with a
codicil added in January 1914, showed her family
ties: she gave her home and land to her brother
Byron in trust for her nephews David and Byron Jr,
and property in Englewood to her niece Jean. And,
she requested that her entire medical library be
given to Dr. Helen Baldwin of New York City.18
In a tribute to Dr. Carrie’s memory, the Bergen
County Medical Society noted: “Her ambition re-
ceived early encouragement and in due time was
well satisfied and rewarded . . . Her brother Dr.
Byron Van Horne, practicing in the same field and
with whom she was in closest sympathy and friend-
ship, is the nearest surviving relative.” □
196
NEW JERSEY MEDICINE
Emma Weeks
Burlington County
On May 19, 1829, five physicians were given the
authorization to create the Burlington County Medi-
cal Society. They met at the Mount Holly Court
House and elected Nathan W. Coles, MD, as presi-
dent.9 This small community of doctors grew at a
steady pace, and in 1896, with 28 members, the
Burlington County Medical Society elected its first
woman member, Emma P. Weeks, MD.
Emma Pauline Weeks was born at home on Sep-
tember 13, 1870, at 10 Washington Street, Riverside.
[This house was diagonally across from the house she
later lived in with her family.] Her father was orig-
inally from Maine and her mother was from
Maryland.19 Emma attended Farnum School in
Beverly, and St. Mary’s Hall in Burlington.1020
At the age of 20, Emma began her studies at the
Woman’s Medical College of Pennsylvania in 1890
and was graduated on May 3, 1893, along with Flor-
ence De Hart, and 47 other graduates. After finish-
ing clinical work in Philadelphia, Emma received
her licenses to practice in New Jersey and Penn-
sylvania, in 1893. 20 Dr. Weeks then returned to her
hometown in Burlington County.15
In September 1893, Dr. Weeks opened a small
practice on 515 Washington Street, and was the first
physician in Burlington County.15,20 In 1896, Dr.
Weeks was elected into membership of the Bur-
lington County Medical Society; she was the 29th
member of the organization.9
At the age of 29, on February 26, 1900, Emma
married William H. Metzer, a New Jersey man, and
continued to practice medicine.20 William and
Emma lived at 119 Pavilion Avenue in Riverside and
had one son, Freeman (1904-1984). 9
Around 1905, Dr. Metzer moved her home and
office to 119 Pavilion Avenue, where she and her
husband lived until 1917; the Metzers then moved
to 428 Fairview Street and Emma maintained an
office at 430 Fairview Street.
Letters noted that Dr. Metzer delivered almost
3,000 babies and made house calls on bicycle and
horse and buggy (that she kept in the barn at 10
Washington Street), and then in a 1910 Mitchell
automobile. She also traveled by rail to Burlington
and then by trolley to Mount Holly to assist Dr.
Alexander H. Small, the first surgeon at Zurbrugg,
in surgery at the Burlington County Hospital. When
Zurbrugg Hospital opened in 1915, Dr. Weeks was
one of the original ten physicians on staff.20
Dr. Metzer was an active participant in county
affairs. And, she was the owner of one of the first
telephones in Riverside, sharing the system with Mr.
Warren C. Pine, the druggist (one ring), and Dr.
Small (two rings). In 1901, she delivered a paper to
her medical colleagues on “Labor.” Dr. Weeks
Metzer opened a maternity hospital at 10 Washing-
ton Street, operating it until 1930. The advertise-
ment for the hospital stated, “The quiet, pleasant
surrounding and home-like atmosphere make our
modern hospital the most desirable place for the
treatment of your medical, surgical, and maternity
cases.”20
On April 28, 1957, Dr. Metzer received the Medi-
cal Society of New Jersey’s Golden Merit Award,
given to physicians who have been in practice for 50
years or more, and she maintained memberships in
MSNJ and the AMA until her death.9
During her lengthy career, Dr. Metzer was af-
filiated with Zurbrugg Hospital in Riverside, and
County Memorial Hospital in Mount Holly. She was
reputed to be “active, versatile, and vigorous.” At
the age of 75, in 1945, she retired. Emma Weeks
Metzer died on April 7, 1964, at the age of 93 of lobar
pneumonia.15 □
VOL. 87— NUMBER 3 MARCH 1990
199
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NEW JERSEY MEDICINE
Sophia Presley
Camden County
Joseph C. Shivers’s hotel in Haddonfield was the
gathering place for five physicians on the morning
of August 14, 1846. Under the leadership of James
S. Risley, MD, the group became the Camden Coun-
ty Medical Society. And, in 1890, this group,
numbering 55, elected its first woman member,
Sophia Presley, MD.
Sophia Presley was born to William and Letitia
Moore in Drumcrin, Ireland, in 1834; at the age of
16, she immigrated to the United States with her
parents and brother and sister. Her family settled
in Steubenville, Ohio, where Sophia’s father was a
glass packer. Sophia completed her education at the
Granville (Ohio) Female Episcopal Seminary, and
was a grammar schoolteacher in Dresden, Ohio, for
four years; she then taught English and mathemat-
ics at Barnett Academy at Charlestown, Indiana, for
three years.2621 Sophia moved to Wellsville, Ohio,
and taught at a school there until 1876. 21
In 1876, she entered the Woman’s Medical College
of Pennsylvania, and was 1 of the 20 graduates of
the medical school in 1879 including Eleanor Galt-
Simmons. Her thesis was on acquired syphilis.216
After being licensed in 1881 in Pennsylvania, Dr.
Presley was invited to become a member of the
Surgical Clinic of the Woman’s Medical College for
one year, and then served as a clinic physician from
1881 to 1884.
A few years later, Dr. Presley settled in Camden
and received her license to practice medicine in New
Jersey. She worked for the City Dispensary and
maintained a private practice “at [a] time in
[Camden] when there was no regular woman phy-
sician practicing in this city — and although at this
early date there was a strong prejudice in employing
a female physician, yet by her earnest zeal and abili-
ty she soon had the confidence of many of our promi-
nent families, and secured a large clientele under
adverse circumstances. It has been reported that her
practice extended to include the best families in the
city, and she is called in consultation with the most
eminent physicians in Philadelphia and other
cities.”921
On November 14, 1882, the Camden County
Medical Society met and the minutes book reported:
“In the case of Dr. Sophia Presley, female practi-
tioner of Medicine, they [censors] were unable to
decide and referred her application to the Society to
act as a body. After discussing the Members and
Resolution by Dr. Marcy which on motion was
tabled. The next meeting was held in May and
Sophia’s application was received and adopted but
at the meeting on November 13, 1883, ‘Miss Sophia
Presley not receiving the requisite two-thirds vote
was rejected.’ ”922
For seven years, Sophia tried to become a member
of the Camden County Medical Society; her appli-
cations repeatedly were rejected until May 1890,
when her name was placed before the 55 members
of the Camden County Medical Society (the State
Society had 1,652 members) and her nomination was
accepted.21
Dr. Presley’s first practice was at Third and Mar-
ket Street and then she moved to 405 Penn Street;
over the next 25 years, Dr. Presley moved nine
times.9
At the 1892 Annual Meeting, the reporter from
Camden County, E.P. Townsend, MD, noted the
county was in a flourishing condition and the Medi-
cal Society was growing because of the need for such
organized medicine — “a strong factor is the ad-
vancement of medical science by the interchange of
personal experience.”9 Dr. Townsend also noted Dr.
Presley reported on antikamnia, a new remedy. The
following year, 1893, Dr. Presley was 1 of 11 mem-
bers (out of 61 members) who responded to Reporter
Daniel Strock’s letter. She reported a case of
cerebral apoplexy, resulting in death, a case of
uterine cancer with an operation, followed by
death. In answer to Dr. Strock’s questionnaire for
the Annual Meeting of 1893, Dr. Presley noted that
strict quarantine was the best measure to prevent
VOL. 87— NUMBER 3 MARCH 1990
201
disease. In his report, Dr. Strock did note the lack
of interest by the physicians who did not respond to
his letters.9
In 1894, Sophia was appointed chairman of the
gynecological department of the City Dispensary. In
addition, she taught at the New Jersey Training
School for Nurses and served on the board of trustees
of the West Jersey Orphanage for Destitute Colored
Children. Dr. Presley was secretary of Camden
County Medical Society from 1894 to 1895. 2,21,22
For every Annual Meeting, the Camden County
Medical Society submitted a summary of events for-
mulated by the appointed reporter. In 1895, Dr.
Presley contributed to this report highlighting some
of her interesting cases: “A case of cholelithiasis, in
which there was no operation, but the patient
passed, by rectum, eight large gallstones, the largest
measuring 15/16 of an inch in its shortest diameter
and 1-1/16 of an inch in its longest diameter; patient
now is doing well. Interesting case of typhoid fever,
with meningitis; at this report, patient is still alive.
Case of constipation and catarrh of the bowels, in
which the lining of the colon and rectum was thrown
off in large worm-like masses, handfuls at a time,
white and tense; recovery.”9 The following year, Dr.
Presley also replied to the reporter’s questionnaire
noting treatments used: “I have used antitoxin in
four cases. Each child had two injections, and to one
of them the third injection was given. At the same
time, the most energetic squabbing, and spraying
was kept up every half hour, only allowing the chil-
dren to have four hours for sleep at night. Antitoxin
may have mitigated the virulence of the diphtheritic
poison, but I am not at all sure about it. I now have
patients taking protonuclein and thyroid extract,
but I can only say that I think the medicines are
doing good.”9 She continued in her report to com-
ment on interesting cases: “Notes of a case of cir-
rhosis of the liver, revealed by autopsy, in an infant
at the age of eight months. No irregularity or jaun-
dice was discovered before the child was three weeks
old. The last symptom before death was dropsy. The
child tapped three times, two quarts and a half-pint
of fluid being discharged in the aggregate.”9
Eighteen hundred ninety-seven was a fairly
healthy year in Camden County, though la grippe
was a formidable epidemic. Sophia served as a del-
egate for the County to the Annual Meeting; the
County Society now had 70 members, and the State
Society had 848. For the next five years, the reporter
noted “quarterly meetings were well attended,
scarcely a member absent.” And, Sophia was active
and involved in all aspects of organized medicine:
“In the county and city medical societies, as well as
the Medical Society of New Jersey, Dr. Presley was
an earnest attendant at the regular meetings, and
taking part in the discussions of the medical subjects
Figure 5. After graduating from the Woman's Medical
College of Pennsylvania in 1876, Dr. Sophia Presley set-
tled in Camden, and became the first woman member
of that county society. (Published with permission,
Camden County Medical Society.)
before the societies.”9
Dr. Presley was the author of numerous papers on
medical subjects (rectal polypi and puerperal fever)
and on nonmedical subjects for the Woman’s Club
of Camden and the Woman’s Park Association. In
addition, she was a member of the American Medi-
cal Association.
Dr. Presley died suddenly at the age of 75 on
November 28, 1909, at her home at 333 North
Seventh Street, in Camden.15,21 Her funeral was held
at St. Paul’s Episcopal Church on Market Street
and it was reported that four of the honorary
pallbearers were women medical doctors of Camden:
Drs. Jennie B. Sharp, Emma M. Richardson, Beulah
Hollinshed, and Lettie Allen Ward. A special meet-
ing of the Camden County Medical Society was held
upon her death, and the following statement was
unanimously adopted by the membership: “It is
with sincere sorrow and regret that the Camden
County Medical Society has learned of the death of
one of its most useful members. ... In all her ap-
pointments Dr. Presley rendered faithful and meri-
torious services.”9 □
202
NEW JERSEY MEDICINE
Anna Hand
Cape May County
Though the physicians of Cape May County tried
to organize a medical society in the early 1800s, it
wasn’t until 1883 that an organized group of practic-
tioners established themselves.20 At the turn of the
century, the Cape May County Medical Society
elected its first woman member, Anna M. Hand,
MD.9
Born at Cape May Court House on January 1,
1849, Anna Maria Hand was descended from Revo-
lutionary War stock, as her maternal and paternal
ancestors were in the war.20 Anna was educated in
her hometown at the House Common School and
completed two years of study at the New Jersey
State Normal School. Anna then taught school for
seven years in Eastern Pennsylvania, until she de-
cided to enter medical school.23 She graduated in
1890 from the Woman’s Medical College of Philadel-
phia along with Caroline Marsh.15
After graduation, Dr. Hand completed post-
graduate work at the Polyclinic Hospital and worked
for two years at the Maternity Hospital and Nurses
School in Philadelphia. She was awarded her Penn-
sylvania license in 1891, and her New Jersey license
in 1892. 2425
In 1892, she returned to her hometown and opened
a private practice at 510 Washington; she was the
first woman physician in Cape May Court House.
Dr. Anna Hand was 1 of the 18 members at the
1901 meeting of the Cape May County Medical So-
ciety, having just been elected into membership. In
1906, Margaret Mace, MD, of North Wildwood,
joined the Society, and there now were 2 women
physicians in the 23-member organization.
In 1909, Dr. Hand was nominated as vice-presi-
dent and served with Virgil Marcy, MD, president.
In 1910, Dr. Hand was elected president, and Dr.
Mace was elected vice-president; the Society had 19
members and the State Society had 1,388 members.
The minutes of the meeting, held at the Hotel
Bellevue, Cape May Court House, recorded this
memorable moment: “The Society enjoys the unique
distinction of being the only one in the state having
a woman president and vice-president.”9 As presi-
dent, Dr. Hand encouraged all members to support
the organization, and invited “all legally qualified
Figure 6. A line drawing of Dr. Anna M. Hand, the first
woman member of our Caoe May County society, was
published in 1897. 23
physicians practicing in Cape May County to unite
with the Society.”
The County reporter, Eugene Way, MD, noted
over the next few years that attendance at meetings
was low: “We regret the lack of interest in the wel-
fare of our Society manifest on the part of many of
our members. This, however, may be due in part to
the fact that the members are widely separated and
means of transportation are not always conve-
nient.”9
After years in Cape May Court House, Dr. Hand
moved to Philadelphia in 1914, where she main-
tained a general practice; her new address was 122
South 17th Street, Philadelphia.15
In 1915, Dr. Hand resigned her membership in the
Medical Society of New Jersey; she did maintain her
membership in the American Medical Association,
and their records note a change of address to Phila-
delphia, until 1918.
In 1918, Anna received her New York license, but
it is unclear whether she practiced in the city. She
lived in New York as of September 3, 1920. On
March 2, 1921, Anna Maria Hand, MD, died at the
age of 72 in New York City.24,25 □
VOL. 87— NUMBER 3 MARCH 1990
205
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NEW JERSEY MEDICINE
Mary Dunlap
Cumberland County
Fourteen physicians met on a cold, winter day,
December 8, 1818, to form the Cumberland County
Medical Society. The group wrote the Society
bylaws, and adopted them at a meeting in January
1819 at Brewster’s Hotel in Bridgeton; they chose
Ebenezer Elmer, MD, as their first president.9 But
the Society remained inactive until 1849, and in
1901, elected its first woman member, Mary J.
Dunlap, MD.
Born in 1853 in Philadelphia, Mary J. Dunlap was
awarded her medical degree in 1886 from the
Woman’s Medical College of Pennsylvania.15 She
practiced in Philadelphia, until Dr. Joseph Parrish,
a friend of Dorothea Dix, was notified of Mary’s good
work, and invited her to become the director of the
Burlington sanitarium for the treatment of “ner-
vously depressed or deranged women with ailments
ranging from insanity to neurasthenia brought on by
ill health or by addiction to drugs.”10,26
On November 15, 1889, Mary became the medical
director and the superintendent of the newly estab-
lished Home for the Feeble-Minded, in Vineland
(now the Vineland Developmental Center). The year
before, the New Jersey Legislature established the
Home under the directorship of S. Olin Garrison; Dr.
Dunlap succeeded him as superintendent six months
later. The Home, located on 50 acres of land, be-
tween farmlands and orchards, featured an adminis-
tration section and an instruction area, where “every
modern method of caring for the state’s dependent
and defective wards is employed. Physical training
in a well-equipped gymnasium is an important fea-
ture of the Home’s life. Well-ventilated and well-
lighted dormitories, with a complete system of water
supply and fire escapes, greatly aid in sustaining the
high standard of healthfulness in the institution.
Other structures comprise a laundry, power house,
supply heat and a pump for raising sewage into the
Vineland system, together with barns and stables.
All the buildings are lighted with gas and electrici-
ty.”26
| \
Figure 7. Mary Dunlap, MD, was the first woman member
of the Cumberland County Medical Society, and served
as the first woman president of the Association of Medi-
cal Officers of American Institutions for Idiotic and
Feeble-Minded Persons. (Courtesy of the Vineland His-
torical and Antiquarian Society.)
Dr. Dunlap’s yearly report detailed her adminis-
trative functions and described her philosophic
ideals. In one report she wrote, “To the inquirer,
‘Can they be cured?’ there is, of course, but one
reply: the condition is not a curable one, but to get
them up and to keep them at a certain standard is
VOL. 87— NUMBER 3 MARCH 1990
207
a gain. The degree of improvement must ever de-
pend on the cause of the disease. We have no medi-
cal restraint or punishment. Close supervision and
moral suasion is the rule. The general interest and
good care exercised by our present assistants is grat-
ifying to me and beneficial to the patients.” Ten
years later, when she was more sure of herself, and
bolder in her style, she wrote: “I am convinced that
the time has come when the state should make ar-
rangements for the better and closer state care of the
tuberculosis poor, and thus remove this widespread
source of infection and contagion to the community
at large. . . . New Jersey, the leader in every good
work for the betterment of her citizens, will not be
behind her sister States in this intelligible form.
Some simple ‘camp’ cottages, high on some of the
health-giving hills, which so fortunately lie within
her own boundaries and in her own possessions,
should be established where — with pure air, the sim-
plest, most nutritive food and hygienic, clean living
rather than manufactured compounds of animal,
vegetable, or mineral kingdom, a compound en-
vironment of harmony of color and symmetry of
lines — there could be found useful employment
adapted to these debilitated unfortunates,
enchained by their destructive bacilli, whether in-
herited or acquired.”27
Dr. Dunlap was recognized as a pioneer woman
administrator of a state institution, and in 1899, she
was elected the first woman president of the Associa-
tion of Medical Officers of American Institutions for
Idiotic and Feeble-Minded Persons (now the As-
sociation for Mental Retardation). In her inaugural
address, she wrote, “Proud that I am a woman, I
rejoice that I have the training as a physician, and
that I can stand, today, your confrere in this conflict
for evolving the best, highest, perfect type of life
human.”28
Nineteen hundred one proved to be an exciting
year for the 36 members of the Cumberland County
Medical Society and Mary. In January, the Society
elected her as their first woman member and on
April 9, 1901, the Society elected their second
woman member, Reba Lloyd, MD. The Cumberland
County reporter noted changes in the Society: “In-
creasing interest, increasing attendance, increasing
memberships, and an increasing number of reg-
ular meetings briefly epitomizes the work of the
Cumberland County Medical Society for the past
year.”9 He also noted that at the January meeting,
held in Bridgton: “Dr. Mary J. Dunlap, a newly
elected member, was present, this being the first
attendance of a woman who was a member, at our
regular sessions.”9
Dr. Dunlap was a very active voice in organized
medicine — she served as the vice-president of the
Society in 1903, and on April 12, 1904, was elected
president of the 46-member Society. This historical
moment — the election of the first woman president
of a New Jersey county society — did not occasion
notation in the minutes of the county society. Dr.
Dunlap also was a member of the American Medical
Association. In addition, Mary was active in civic
affairs: she was a director of the New Jersey Legal
Aid Association for Women, a life member of the
Vineland Historical and Antiquarian Society, and a
charter member of the Vineland Women’s Club.26
In 1906, a report on the Home noted Dr. Dunlap’s
contributions: “Not a step in its development that
has not the impress of Dr. Dunlap’s mind and heart.
She speaks of it as her lifework. Its order, domestici-
ty, cheerfulness, and charm are of her and from her.
In the wider range of her influence must be reckoned
the outside recognition given to her abilities and
character.”26
On April 13, 1909, Dr. Dunlap resigned from the
Cumberland County Medical Society; the secretary
noted that “the efficient medical superintendent re-
signed and it was accepted with regret.”9 On May
1, 1909, she married Clarence Snyder of Racine, Wis-
consin.
Mary then resigned as superintendent of the
Home for the Feeble-Minded and was replaced by
Dr. Madeline A. Hallowell. The Dunlaps moved to
Figure 8. Dr. Hallowell served as superintendent of the
Home for the Feeble-Minded in Vineland, after Dr.
Dunlap resigned. (Medical Society of New Jersey.)
Wisconsin iater that year. Mary’s husband,
Clarence, was well known and respected in Racine.
Born in New York City on March 12, 1853, Clarence
moved to Wisconsin in 1873. He was a teacher, local
editor, attorney, justice of the peace, postmaster of
Racine, insurance agent, and editor and publisher
of the Daily News of Ashland, Wisconsin. Two years
before his marriage to Mary, in 1907, he founded and
promoted his own company, the Racine Heel Protec-
tor Company, a knit product placed inside a shoe
to prevent slippage.29 Soon after the outbreak of
World War I, they moved to New York City with
Clarence’s son from his first marriage to Isabel
Elkins. Clarence died shortly after this move, and
Mary returned to Racine; she was listed in the city
directory as a widow in 1923 but records do not list
her anytime after that date. □
208
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Eleanor Haines
Essex County
On June 4, 1816, five physicians met at Moses
Roff s Inn, on Broad Street, in Newark, to organize
the third county medical society in New Jersey. The
group elected John D. Williams, MD, as its first
president, and from that day forward the organiza-
tion grew and prospered. And, in 1876, the Essex
County Medical Society was the second county so-
ciety in New Jersey to induct a woman member,
Eleanor (Ella) Haines, MD.
Born in 1846, Ella Haines was born to Alfred C.
and Fanny Swann Bradley; her father was a New
Jersey physician, and her maternal grandfather, Dr.
Joseph Bradley, was a Philadelphia doctor. (Her
brother Byron also became a physician.) Ella
entered the Woman’s Medical College of Penn-
sylvania, and was one of the two graduates of the
class of 1871. 15'25-30
After graduation, Dr. Haines was awarded her
Pennsylvania and New Jersey licenses. She settled
in Newark, and opened her practice at 41 Bank
Street. In 1876, with five years experience to her
credit, Ella applied for and was granted membership
in the Essex County Medical Society.9 The 60-year
old organization was the largest county society, with
56 members (12 percent of the membership).
Her reputation as a physician was great; she was
respected and admired: “She had an unusual record,
it having been said of her that she never lost a case
of pneumonia, scarlet fever or diphtheria, except in
a few instances where she was called in after the case
had progressed too far for medical aid. Dr. Haines
had a large circle of personal friends in this country
and abroad. During her many years of active work,
she gave much time to the poor, giving her services
freely, and contributing largely of her means.
Though her mature life was spent almost wholly in
the city, she never lost her childhood love of life in
the open and had a passion for flowers.”25
As her practice grew, Dr. Haines moved to a home/
office she had built at 934-936 Broad Street, in New-
ark. Dr. Haines served Essex County Medical So-
ciety as a delegate to the Annual Meeting, rep-
resenting the county in 1894, in 1911, and in 1912.
In addition to her membership in the Medical So-
ciety, Dr. Haines had a great many interests and was
affiliated with the Daughters of the American Revo-
lution, the New Jersey Historical Society, the Na-
tional Geographic Society, and the Colonial Dames.
It was reported that Dr. Haines was a shrewd
businesswoman as well as good doctor: “Although
singularly lacking in the desire for personal publicity
characteristic of some successful women, was a re-
markable personality to those who had the privilege
of her friendship. . . . When she was graduated from
medical college it required high determination to
adopt a profession then deemed entirely inap-
propriate to her sex. Dr. Haines not only overcame
this prejudice, but made a place for herself equal to
any of her contemporaries. She naturally espoused
the cause of suffrage when ‘woman’s rights’ were
exceedingly unpopular and lived to see them become
ultra-fashionable.”30 She was one of the earliest in-
vestors of the Prudential Insurance Society, proving
her business acumen.25 And, she bought the property
on the southeast corner of Broad and Franklin
Streets in Newark that increased in value ever since
her purchase.30 Dr. Haines retired around 1914, but
she did “receive a few at her office for advice.”30
Dr. Haines remained a member of the Essex
County Medical Society until her death at home on
April 23, 1924, of senility, at the age of 78. 915 Upon
her death, a report presented at the Annual Meeting
of her alma mater noted the following: “[Her] house
was filled with souvenirs of her wide travels in this
country and abroad. She had been around the world
and visited many points of interest more than once.
To know her own country well was one of Dr.
Haines’s special ambitions, and many trips within
its borders were made by her. She was aboard the
first passenger vessel to pass through the Panama
Canal. . . . She was a supporter of the suffrage move-
ment for women before it was a popular cause and
of other welfare undertakings for women and for
children, and a liberal contributor to church and
charitable societies. Having lived here [Newark] for
many years, Dr. Haines was identified with the busi-
ness interests as well as the philanthropic under-
takings.”25
Her last will and testament noted her final
thoughts: “I feel that whatever estate I leave has
been acquired in my professional work and should
ultimately revert to charitable societies in my field
of labor.” After her family and friends were given
their bequeaths, the residue was given to the Home
for Crippled Children, the Women’s and Children’s
Hospital, and the Baptist Home for the Ages.30 □
VOL. 87— NUMBER 3 MARCH 1990
211
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NEW JERSEY MEDICINE
Ruth Clement
Gloucester County
On December 8, 1818, while Cumberland County
was busy organizing their medical society, 13 physi-
cians from Gloucester County met at the Public
House of Jesse Smith in Woodbury to create the
Gloucester County Medical Society.12 These medical
men elected Dayton Lummigas, MD, as the first
president of this organization. The group met two
times a year from 1818 to 1821; meetings were re-
sumed in March 1830, but soon were suspended. In
1846, the Gloucester County Medical Society was
issued a new charter and regular meetings soon were
the order of business. Originally, Gloucester County
contained Camden and Atlantic counties, but with
the division, the medical society was referred to as
Old Gloucester County Medical Society.
A small, tightly knit community, Gloucester
County maintained its size and its “small-town”
image. It wasn’t until 1915, when Henry L. Sinexon,
MD, was president, that the Gloucester County
Medical Society elected its first woman member,
Ruth Clement, MD.9 The Society had 25 members,
and the State Society was composed of 1,607 phy-
sicians.
Born to Mark and Katherine McDermot Clement
in 1848, Ruth spent her childhood in Paulsboro.
After finishing her early education, she worked for
the Philadelphia Mint and then went to medical
school. Ruth received her medical degree from the
Woman’s Medical College of Pennsylvania on March
14, 1889. She worked in the college hospital for a
number of years and then opened a private practice
at 1523 Race Street in Philadelphia.51 She was
awarded a Pennsylvania medical license in 1889 and
a New Jersey medical license in 1907. 1015 A regular
physician, Dr. Clement opened a private practice in
National Park around 1915, that she maintained
until her death. In National Park she worked as the
medical inspector of the schools in addition to her
office practice.31
Minutes from County Society meetings rarely
mention her name. In 1921, Dr. Clement was elected
one of five delegates to the Camden County Medical
Society and was re-elected the following year.9 Dr.
Clement’s name was noted on the roll call at the
February 25, 1924, meeting.
Dr. Ruth Clement died at home on January 26,
1925, at the age of 77, from a cerebral hemorrhage;
she was buried at Eglinton Cemetery.915 There was
a tribute to Dr. Clement from Sarah Palmer Byrnes
that appeared in the Alumnae Association Trans-
actions in 1925:
The death of Dr. Ruth Clement after some
years of gradually failing health removes a
woman of a very rare personality from our
midst. Her singularly buoyant freshness
and freedom of spirit which rose above the
commonplaces and trivialities of life, which
turned tragedy into comedy every day in
the week, turned tears into smiles, and
brought health and healing by sheer per-
sonal force and charm and sincerity of
character, was remarkable and unique.
Struggling hard to obtain her professional
ambition against many odds, she achieved
a degree of success which only those she
helped can measure, and which only failing
strength and advancing years has limited —
vaccine physician, medical inspector, was a
member of the Gloucester County Medical
Society, Browning Society, Press Club, etc.
and (what few of her large circle of ac-
quaintances probably knew) was really
gifted as a poetess when moved. A daughter
of friend Catherine Clement, associate of
Lucretia Mott and other active abolish-
ionists and public-spirited reformers of a
generation ago, both she and her sister,
Anne L. Clement, have entered actively
into the life and uplift of every community
in which they have settled. To those who
leaned upon her even in her frailty — for
cheer and support, her family and friends,
her loss is unmeasurable. Her friendship
was a rare jewel, and fortunate are those
who have possessed it.6
At the time of her death, there were 30 members
of the Gloucester County Medical Society. A brief
obituary in the March 1925 issue of The Journal of
the Medical Society of New Jersey stated Dr. Cle-
ment had been an active member of the Gloucester
County Society and of MSNJ. □
VOL. 87— NUMBER 3 MARCH 1990
213
'
Florence De Hart
Hudson County
In 1840, a new New Jersey county was formed
when a portion of Bergen County was reproportioned
to create Hudson County. Though the new bound-
aries confused some of the townspeople, the phy-
sicians were interested in forming a new Society to
better care for the local communities. A charter was
granted to form Hudson County Medical Society on
May 13, 1851, and the Society held its first organiza-
tional meeting in October with 37 members.9 Forty-
eight years later, Hudson County Medical Society,
under the leadership of President Charles K. Law,
MD, opened its doors to its first woman member,
Florence De Hart, MD. By 1889, the Hudson Coun-
ty Medical Society boasted 72 members of the 879
members of the State Society.
Florence De Hart was born on August 30, 1871, one
of four children. Her parents were well educated and
expected the same of the children in the family. Her
father was John Somers De Hart, originally from
Mount Freedom; he graduated from Princeton Uni-
versity in 1860 and then received his law degree in
1864 from Princeton University School of Law. After
graduation, he moved to Jersey City where he prac-
ticed for 40 years. Soon after moving to Hudson
County, John De Hart married Dr. Lucy Madana
Batcheller Fuller (1840-1911) in 1868. Lucy was a
physician who practiced in Jersey City. They lived
at 8 Paulnier Place, eventually moving to 99 Mercer
Street.10’ 32
Florence De Hart graduated with Emma Weeks
from the Women’s Medical College of the New
York Infirmary in 1893; a year later, her sister
Clara graduated in the class of 1894. Florence re-
ceived her New Jersey license in 1893 and her New
York license in 1895. Immediately after graduation.
Dr. De Hart interned at the New England Hospital
for Women and Children, Boston, and then returned
home to practice with her mother and her paternal
aunt, Sarah, at 99 Mercer Street, Jersey City.32
Dr. De Hart joined the Hudson County Medical
Society in 1899 and remained an active member
until 1902. At that time, Dr. De Hart was 1 of 137
members of the County, the second largest county
membership in the state (the State boasted of 1,061
members). According to letters from a Society re-
porter, Dr. De Hart did not attend State Society
meetings, but attended County Society affairs.9
After resigning her membership in the State So-
ciety, Dr. De Hart became the resident physician for
the State Home for Girls in Trenton. Her brief obitu-
ary in the Journal of the Medical Society of New
Jersey noted she died suddenly from intestinal dis-
ease at the Home in early February 1906. 9 □
Figure 9. Dr. Luther Halsey was president of the State
Society when Dr. De Hart was elected into membership.
(© Medical Society of New Jersey.)
NEW JERSEY MEDICINE
-1
214
Alice Clark
Hunterdon County
Hunterdon established its county medical society
in 1821. Physicians met in Flemington on June 12,
1821, and appointed Nicholas Belleville, MD, as the
first president. But the Society did not prosper and
a reorganization was attempted in 1836. 12 Finally, in
1846, the Hunterdon County Medical Society was
able to establish itself as a permanent professional
association. It was not until 1936 that the Hunterdon
County Medical Society elected its first woman
member, Alice Lampham Clark, MD.'
Alice Lampham was born on September 9, 1903,
in White Cloud, Michigan; she had an older brother
and two younger sisters. The family moved during
her teenage years, and Alice graduated from Inter-
national Falls High School in Minnesota. In 1926,
Alice received her bachelor of science degree from
Syracuse University, New York. Soon after gradu-
ation, Alice married Joseph D. Clark, and her ad-
dress was listed as Akron, Ohio.32
*
Figure 10. A member of the graduating class of 1933 at
the State University of New York at Buffalo, Dr. Alice
Clark became the first woman member of our Hunterdon
County Medical Society. (Published courtesy of Univer-
sity Archives, SUNY at Buffalo.)
While Joseph completed a doctorate in chemistry,
Alice entered medical school. Notes from the dean
stated Alice was well liked as a student, and gradu-
ated in good standing, being number 24 in a class
of 65 students. She was awarded her medical degree
from the University of Buffalo School of Medicine
on June 14, 1933. She served an internship at Buffalo
City Hospital; she was awarded her New York
license in 1933 and her New Jersey license in 1934. 34
Joseph worked as a research chemist and spent
time in Peru while Alice remained at home. A gen-
eral practitioner, Dr. Clark opened a practice in
Lambertville in 1934. 9,32 Her practice was largely de-
voted to family care, and Alice delivered many chil-
dren in the local community, including the children
of her sisters and brother.
In 1936, the Hunterdon County Medical Society
had 21 members; the State Society was composed
of 2,839 members. Alice was elected in 1936 and
remained a member until 1938. On December 8,
1938, she joined the Mercer County Medical Society
and for the next 16 years was an active participant.
She had an office at 206 West State Street in Tren-
ton, resided in Toms River, and was affiliated with
Mercer Hospital, Trenton.9
In addition to her membership in MSNJ, Dr.
Clark was a member of the American Medical As-
sociation and the American Medical Women’s As-
sociation.
In 1955, Dr. Clark applied for staff privileges at
Point Pleasant Hospital, and at the age of 54, she
moved her practice to her home at Gary Road, in
Toms River. In 1957, she joined the Ocean County
Medical Society and remained a member until her
retirement in 1966. During these years, Alice was in
semi-retirement with her husband, working part-
time as a general practitioner. Dr. Clark devoted
many hours to working for the First Aid Society and
volunteering for many civic activities, especially
with the young adults of Toms River.33
She and Joseph retired to Riverview, Florida. Liv-
ing as a widow in the home she and her husband
built on a lake, Dr. Alice Clark now is under the
constant nursing care of her family.32 □
VOL. 87— NUMBER 3 MARCH 1990
215
S. Mabel Grier
Mercer County
A resolution was passed in 1848 allowing five phy-
sicians in Mercer County to organize a county so-
ciety. The doctors met at the house of Samuel Kay
in Trenton on May 23, 1848, and elected John
McKelway, MD, as its first president.12 And in 1907,
the Society inducted its first woman member, S.
Mabel Grier, MD.
William T. Grier and Mary West were married in
1879; the following year, their first child, Sarah
Mabel Grier was born on July 30, 1880, and in 1884,
Sarah’s brother, William A.W., was born.36
Sarah graduated Salem High School and com-
pleted her undergraduate education in 1901 at Buck-
nell College in Pennsylvania. She received her medi-
cal degree from Johns Hopkins School of Medicine,
Baltimore, Maryland, in 190537 [The first coeduca-
tional class at Johns Hopkins was in 1893.] Two
years later, she received her license to practice in
New York and New Jersey, and she moved to 32
West Street, Trenton.
On December 10, 1907, the Mercer County Medi-
cal Society inducted S. Mabel Grier, MD. The So-
ciety had 73 members and was in a state of growth
and development. Dr. Grier’s name disappears from
the fdes after 1909. 9 Her records do show a name
change to Mabel Grier-Lesher and a move to 247
East 8th Street, in Watsontown, Pennsylvania.15
During the 1920s, Dr. Grier-Leisher was a mission-
ary in China, in the province of Sow Chow, with the
American Baptist Foreign Missionary Society or the
Protestant Missionary Society.3638 Dr. Grier died on
September 11, 1969, at the age of 88. □
Caroline Marsh
Middlesex County
Five New Jersey counties organized local medical
societies in 1816. Middlesex County physicians
created the fifth group when eight physicians met
on June 13, 1816, and 76 years later the Middlesex
County Medical Society elected their first woman
member, Caroline H. Marsh, MD.9
Caroline Hempstead Marsh was born in 1863. She
received her medical degree from the Woman’s
Medical College of Pennsylvania in 1890 with her
classmate Anna Hand. Caroline was listed as a reg-
ular physician.10 In 1891, Caroline was awarded
licenses to practice in New Jersey and Pennsylvania.
That same year she applied to the Middlesex County
Medical Society, and was accepted as the 25th mem-
ber. Dr. Marsh’s name is listed on the roster through
1894, but then her name was dropped from the mem-
bership listing.
In addition to her membership in the Middlesex
County organization, Dr. Marsh was a member of
216
the American Medical Association. Though a year
was not given, she did write to the AMA and inform
them she was married and thereafter was listed as
Caroline H. Marsh-Wikle Farrell.615
In February 1913, Caroline listed her practice in
Johnstown, Pennsylvania. During this time, Dr.
Marsh worked for Dr. Bertha Caldwell of Johnstown.
Neither one of these women were members of the
Cambria County Medical Society of the Penn-
sylvania Medical Society simply because women
were not accepted as members.39
In 1914, Caroline returned to New Jersey, to
Metuchen, and then in December 1914, her AMA
address card noted a move to Garwood.15 Dr. Marsh
returned to Pennsylvania, to Cresson, in 1918, and
then moved back to Johnstown, and Dr. Caldwell’s
practice.1539
Caroline died at the age of 59 on January 15, 1922,
in Pennsylvania. □
NEW JERSEY MEDICINE
Sarah Mackintosh
Monmouth County
P issaic County
In 1843, the physicians of Passaic, a county with
17,000 residents, applied for a charter to organize a
medical society. The charter was granted in January
1844; the Passaic County Medical Society held its
first meeting and elected Garret Terhune as the first
president. Less than 30 years after this meeting, the
Passaic County Medical Society inducted its first
woman member, Sarah Apfonda Mackintosh, MD.
Sarah Apfonda was born in New York City in
January 1836 to a prominent and well-to-do family.
Her father, a born-and-bred New Yorker, was a
major in the Army and her mother was originally
from New Hampshire.40
At the age of 33, Sarah entered the Women’s
Medical College of the New York Infirmary, one of
nine students in the class of 1872.' Before Sarah
graduated from medical school, she married James
Hetherington Mackintosh of Paterson, a pharmacist
attending medical school at Bellevue Hospital Medi-
cal College in New York City. Sarah’s final project
for her senior thesis was on syphilis. Both Sarah and
James received their medical degrees in 1872. Sarah
and James then had three children: James Alex-
ander (1872-1957); Sarah F. (1873-1956); and Lillith,
who died in infancy.
In 1872, the Drs. Mackintosh moved to Paterson
and began a private practice. On October 7, 1872,
Sarah Mackintosh, MD, became the first woman
member of the Passaic District Medical Society, and
eight months later, in June 1873, made further his-
tory by becoming the first woman member of the
Medical Society of New Jersey.9
The Passaic County Medical Society was or-
ganized in 1844; by 1872 there were 28 members. The
minutes from the October 1872 meeting listed five
new members, including Sarah and James.
Two years later, the Drs. Mackintosh established
a new private practice in a combined home/office at
136 Carroll Street; in 1886, they moved to 194 Carroll
Street.41
Sarah Mackintosh was one of the few women phy-
sicians to take an active role in organized medicine.
Soon after her induction into the State Medical So-
ciety, she presented a paper to the membership in
1874 on the use of chloral hydrate in labor — the first
woman to make a presentation to this all-male or-
ganization.9 In 1876, Sarah became the county re-
porter for the Passaic County Medical Society.
Sarah was absent from the 1876 meeting, but sent
a communication with her husband who presented
it at the 110th Annual Meeting on May 23, 1876, at
Cape May City. The report detailed the work of the
30 physician-members.
Sarah Mackintosh belonged to other societies. In
1878, she became a member of the Association for
Advancement of Medical Education for Women; her
name, along with that of Dr. Elizabeth Blackwell,
appeared on a report issued from a meeting of this
group that took place in Union Hall, New York City.
In addition, Sarah was elected Secretary of Ladies
Hospital in Paterson in 1873 — one of four officers.
Ladies Hospital, first known as The Hospital of the
Ladies Association, was created in 1871 by the
women of the Paterson Benevolent Society. A public
institution, that became Paterson General Hospital
in 1887 and today is Wayne General Hospital,
opened to accommodate the growing need for hospi-
tal facilities in booming Paterson. The hospital was
considered “a ladies enterprise, the ladies alone
would have the management of it.”42
The Mackintosh family relocated to Asbury Park
in 1887, where they bought a house/office at 515
Third Avenue. As soon as the family was settled,
Sarah applied for membership to the Monmouth
County Medical Society.
The Monmouth County component of the Medical
Society of New Jersey was organized on June 3, 1816,
in the Court House in Freehold. The physicians
elected William G. Reynolds, MD, as the group’s
first president. In 1888, the Society elected Dr.
VOL. 87— NUMBER 3 MARCH 1990
217
: ■ I m istetea MTU dm
33JSOK5 Ml JQ. ijr ^iif .? «J. J j!.
* ^ ■&'&$% IS^s; Ojr asaffepadf
Figure 11. Dr. Sarah Mackintosh was buried in Cedarlawn Cemetery, Paterson; she was the first woman member
of our Monmouth and Passaic County components, and the first woman member of the Medical Society of New Jersey.
Dr. Mackintosh was active in Society affairs and served as County Reporter in 1876. In 1878, she became a member
of the Association of Medical Education for Women, along with Dr. Elizabeth Blackwell. And in 1873, Dr. Mackintosh
was elected secretary of what today is Wayne General Hospital.
Mackintosh, and added her name to the 44-person
roster. Sarah made history again by becoming the
first woman member of the Monmouth County
Medical Society.9 Sarah remained a member of the
Monmouth County Medical Society for 15 years, but
there is no information on her contributions to the
organization.
The Mackintosh family again moved; this time to
West Fifth Avenue in Asbury Park. Sarah was
awarded privileges at Monmouth Medical Center,
Long Branch, and remained an active staff member
until her death. Dr. Sarah Mackintosh died at home
in Asbury Park on October 19, 1903, and was buried
in the family plot in Cedarlawn Cemetery in
Paterson. Her tombstone reads: “A true wife, a de-
voted mother, and a generous friend of the poor.”
Obituaries appeared in the Asbury Park Journal and
included the following: “Dr. Sarah Mackintosh was
probably one of the best known women in Asbury
Park . . . [She | did many kind and graceful acts of
charity. She was always ready to give when called
upon and did a great deal for the poor people of this
city and surrounding towns in a quiet and unosten-
tatious way.”'"’ □
218
NEW JERSEY MEDICINE
Emma Clark
Morris County
On June 11, 1816, the Court House in Morristown
was busy, as seven physicians organized the Morris
County Medical Society. They elected their first
president, Lewis Condict, MD, and met for the next
40 years.9 In 1857, meetings were suspended due to
a lack of interest and it was not until 1873 that the
group was reorganized. From this point in time, the
Morris County Medical Society grew and prospered,
and in 1906, Emma Chambers Clark, MD, was
elected to membership.
Emma Chambers Clark was born on September
26, 1866, in Malone, New York, to William and
Elizabeth (Chambers) Clark. She entered medical
school in 1899 and was 1 of 3 women in the 21-
member graduating class of Syracuse University
School of Medicine in 1902. Emma was the associate
editor for the 1902 Onondagan, the school’s year-
book, and a member of the Alpha Chapter of the
Zeta Phi Fraternity. (Elizabeth Blackwell was the
charter member of this organization.)43
Figure 12. Dr. Emma Clark was 1 of 7 women in the 21-member graduating class of Syracuse University Medical
School in 1902. Dr. Clark is seated in the second row, second from the right. (Published with permission, George
Arents Research Library, Syracuse University.)
VOL. 87— NUMBER 3 MARCH 1990
219
After graduation, Emma was awarded her New
York license and she joined the staff of the Sani-
tarium in Clifton Springs, New York, as a
pathologist, from 1902 until 1906. The Alumni Direc-
tory from Syracuse University also noted that Dr.
Clark was listed as a general physician in New York
in 1906. 15,42
Dr. Clark applied for and received her New Jersey
license in 1905 and the following year moved to
Dover. A pathologist, Dr. Clark became affiliated
with Dover General Hospital and served the institu-
tion until her death at age 57 on November 17, 1923.
Reporters for the Morris County Medical Society
recorded County events with regularity. At the
March 13, 1911, meeting, Dr. Vinton gave “an
interesting talk on the work of the Public Health
Committee.” Dr. Clark, who attended this meeting,
became the chairman for a committee to perform
local volunteer work. This was to be the first of many
such endeavors for Dr. Clark. The following year, at
the March 12, 1912, meeting, Dr. Clark “made a
personal canvas of the members present for help in
the campaign for the betterment of public health
which the national committee is organizing for the
last two weeks in May.” Emma succeeded in finding
volunteers, to help her in this crusade.9
Figure 13. Dr. Clark was elected into membership in
1906, when Dr. Alexander Marcy, Jr, was president.
(© Medical Society of New Jersey.)
At the meeting held on September 10, 1912, three
discussion groups were held; Dr. Clark was the mod-
erator for the talks: “Are Institutions for Tubercu-
losis a Menace to the Community?” “Is the Press
a Reliable Source of Information Relating to the
Status of Medical Science?” “Is Medical Inspection
of Our Public Schools a Farce?” After the speakers
concluded, the reporter noted Dr. Clark’s remarks:
“Dr. Clark said that the Dover school was the first
in the state to carry out the regulations as to inspec-
tion proposed by the State Board of Health. The
work was divided into three parts — inspection of
school buildings, the pupils in the school, and all
pupils who were reported sick in the district. She
220
said that all their suggestions regarding the build-
ings had been given careful consideration and gener-
ally adopted. That several patients reported sick had
been found to be suffering from such infectious dis-
eases as scarlet fever. Isolation had prevented an
epidemic. She further said that numerous cases of
bad suppurating ears had been successfully treated
and asked if any one knowing these facts could
honestly say that school inspection was a farce.”9
Though her name was not mentioned in the Coun-
ty Reporter’s minutes for the next few years, Dr.
Clark did attend the meeting on June 18, 1918, at
the All Souls’ Hospital in Morristown; her name was
listed among the participants of the discussion group
at the meeting.
In addition to membership in the Morris County
Medical Society, Dr. Clark was a member of the
American Medical Association; she was affiliated
with both groups until her untimely death on No-
vember 17, 1923, of chronic myocarditis.15
At the December 11, 1923, meeting of the Morris
County Medical Society, the following memorial9 to
Dr. Clark was unanimously adopted:
Death, the great and unsparing reaper, re-
cently entered our Society and took from us
our respected colleague, Dr. Emma C.
Clark.
Dr. Clark had a most retiring and self-effac-
ing disposition; so much so that her in-
timate association with many of our mem-
bership was limited. But with those who
knew her best, her sterling worth impressed
itself upon them.
Dr. Clark was a woman of the highest type;
therefore, as a physician she was true to her
chosen profession. Her ideals were high, so
high that she failed to reach them. Her last
words spoken at a medical meeting in our
little hospital in Dover were: “I tried so
hard. I had planned so much; my strength
failed me.” She was speaking of her work
in the laboratory, of how she had hoped to
enlarge and better it.
We shall long miss Dr. Clark and think of
her as one of the Creator’s choice handi-
works.
We would extend our sincere sympathies to
her aged mother who is so sorely afflicted
and the three remaining sisters who mourn
her loss.
Dr. Clark looked death in the face with
thorough calmness, preparing quietly for it
as though for a vacation and rest.
She is resting. □
NEW JERSEY MEDICINE
III
Marie Chard
Ocean County
In 1861, the administrators of the Medical Society
of New Jersey felt Ocean County would be suitable
for a component society. Drs. Hilliard and Disbrow,
members of Monmouth County Medical Society,
questioned the Ocean County physician population,
about such a proposition. The local physicians,
though, did not organize a medical society until
1874, and two years later, the Ocean County Medical
Society became an established organization. The So-
ciety held meetings and members attended the State
Society annual meetings, until 1895; the Society
then suspended all activities for eight years. In 1903,
ten physicians reorganized the Ocean County Medi-
cal Society, and five years later elected its first
woman member, Marie Louise Chard, MD.
Born in 1868, Marie Louise Chard was one of 25
graduates of the 1895 class of the Women’s Medical
College of the New York Infirmary for Women and
Children. After receiving her New York medical
license in 1895, she was a one-year assistant phy-
sician in the out-practice. In a report from the Medi-
cal College, it was noted that this was not easy work,
for the physicians attended sick women and children
in tenement houses.43'44 Living at West 34th Street,
New York City, Dr. Chard was an assistant demon-
strator of anatomy for the Women’s Medical College
from 1897 until 1899. In 1898, she served as a house
physician, and from 1896 to 1907, she also served in
the Department of Surgery in the dispensary of the
Infirmary.44 In addition, from 1902 to 1905 she was
a junior attending surgeon.
Dr. Chard was affected personally and pro-
fessionally by Emily Blackwell’s decision to close the
Women’s Medical College; Dr. Chard wrote to Dr.
Blackwell and received the following letter: “The
opening of Cornell is a great step forward, and I hope
all our young doctors will feel that however much
they may at first regret the college, the whole change
is an advance. I hope the Infirmary may become a
center that will be ever more valuable to you all. I
am glad you are working in it. I do greatly appreciate
the good will and regard of all you younger workers,
and I send my best wishes for growing interest and
success of your work.”
In 1908, Dr. Chard relocated to Lakewood. And,
at the October 24, 1908, meeting of the Ocean Coun-
ty Medical Society, Dr. Chard was inducted into the
19-member organization. Dr. Chard was known as
a regular physician in Lakewood, and practiced
there for the next 11 years.9
During her years as a member, she rarely attended
County Society meetings, usually held in the home
of the County Society president. (As the only female
member of this organization, she may have de-
liberately remained in the background, for her name
never was mentioned in the reporter’s minutes.)
In September 1920, Dr. Chard moved her
gynecologic and consulting practice back to New
York City, to 121 East 60th Street. Though she
maintained her membership in the Union County
Medical Society until 1922, she already had joined
the Medical Society of the State of New York.9
Marie was active in New York State and national
medical organizations: she was a fellow of the Ameri-
can College of Surgeons (1913); and was a member
of the American Medical Association, of the New
York Academy of Medicine, of the Women’s Medical
Association of the City of New York, of the American
Medical Women’s Association, and of the Medical
Women’s International Association.
An advocate for medicine, Dr. Chard’s first love
was creating opportunities for women physicians.
During World War I, she helped to establish the
American Women’s Hospitals, and served on its Ex-
ecutive Board until her death.44 The American
Women’s Hospital, with Dr. Chard’s assistance,
financed trips for 15 American women physicians
and three dentists to the War Zone. Dr. Chard was
VOL. 87— NUMBER 3 MARCH 1990
221
Figure 14. Dr. Marie Chard was the first woman member of our Ocean County
component. She was very active in organized medicine. (Published with per-
mission, The New York Academy of Medicine.)
a participant of the Medical Women’s National As-
sociation War Service Committee (created in 1917).
An able fundraiser, Dr. Chard helped to raise
$200,000 for the War Service Committee.10'4'1
While fundraising for the War Service Committee,
Dr. Chard also campaigned for monies for the Post-
graduate Medical College and Hospital, New York.
In addition to the funds, Dr. Chard served on the
medical board from 1906 until 1927, and on the
board of trustees from 1920 until her death 18 years
later. During her affiliation with the College and
Hospital, Dr. Chard was an assistant to Dr. Willy
Meyer, in the Department of Surgery.
Dr. Chard was appointed to the second War Ser-
vice Committee in June 1918, and in 1923 was reap-
pointed, serving until her death. An article written
shortly after her death noted that Dr. Chard “was
deeply interested in the American Women’s Hospi-
tals, and the opportunities for women physicians
this service made possible, as it extended from coun-
try to country, including Albania, Armenia, France,
Greece, Japan, Russia, Turkey, Yugoslavia, and fi-
nally impoverished parts of the United States.”44
On January 20, 1938, at the age of 70, Marie
Louise Chard, MD, died of myocarditis. A brief
obituary appeared in the New York Herald Tribune
two days later, noting her work as a surgeon in New
York City for 30 years.15 □
222
NEW JERSEY MEDICINE
Ellen Smith
Salem
Seven physicians from Salem County organized
their component medical society and held its first
meeting on November 30, 1818. On May 4, 1880,
Salem County Medical Society was reorganized, and
almost 100 years from the Society’s first meeting,
Salem County physicians elected a woman member,
Ellen B. Smith, MD.J
The second child of Mary Bradway (1836-1925)
and Quinton P. Harris (1830-1919), Ellen Harris was
born in Lower Alloways Creek Township on January
26, 1866, four years after the birth of her sister Lucy.
Ellen attended local public schools and graduated
Salem High School in 1884. She was a member of
the 1892 class of the Woman’s Medical College of
Pennsylvania, and received her New York and New
Jersey licenses that same year.10,36’45
After graduation, Ellen moved to Brooklyn, New
York, and opened a successful practice. She married
Winfield Scott Smith on May 19, 1891. [Dr. Winfield
Smith was born on August 5, 1862, at Hancock’s
Bridge; he graduated from Long Island College of
Medicine in 1878. He moved to Brooklyn and was
on staff at Long Island Hospital.]46 After their mar-
riage, the Drs. Smith continued to practice in New
York City.
A few years later, the Drs. Smith moved to Salem
and practiced at their home/office on East Broad-
way. Ellen’s practice “became very extensive, es-
pecially among women and children.”45 Ellen took
a keen interest in community affairs serving as presi-
dent of the Woman’s Club of Salem in 1904, as the
chairman of the Department of Public Health in the
New Jersey State Federation, and the National Fed-
eration of Women’s Clubs, and as a member of the
Oak Tree Chapter of the Daughters of the American
Revolution.
When she was elected to membership in 1916, Dr.
Smith was 1 of 24 members of this County Society,
with the state organization having 1,684 members.
Known as Dr. Ellen, she was one of Salem Coun-
ty’s most prominent and best known citizens. Dr.
Ellen “had a large circle of close friends and adoring
patients. There was perhaps no physician in the
county who was closer to those to whom she minis-
tered than was Dr. Ellen. She took more than a
professional interest in her cases; she took deep and
loving care of each one.”45 Newspaper accounts of
her professional career noted: “In her busy life she
County
not only found time to attend to those patients who
were amply able to pay for her services but she also
was never too tired nor too busy to give her minis-
trations to the poor. . . . she gave such unremitting
and unselfish attention to those who needed her
care.”45
Dr. Ellen also was concerned about women in the
medical field. “She pleaded that Club women
should realize themselves and endeavor to impress
upon their daughters and young friends the very
promising careers opened to women in the medical
profession.” In an article, she wrote: “As to the mon-
etary rewards they are good, but they are the least
of the returns that await those who elect to follow
in the footsteps of The Great Physician.”45
On May 13, 1920, Dr. Ellen Smith died at the age
of 54 from a fractured skull following an accident on
East Broadway in Salem. Crossing the street on the
night of her death, passersby noted heavy rain and
possibly her umbrella obscuring the view of an ap-
proaching automobile. She was thrown violently into
the roadway, and apparently was dead at the scene
of the accident. The driver of the automobile took
Dr. Smith to Salem County Memorial Hospital, but
she already had died.6-45
A resolution passed by the Salem County Medical
Society9 noted her contributions:9
This splendid service in the cause of reliev-
ing suffering humanity was best exhibited
in her untiring, self-sacrificing devotion to
their conscientious duty well performed.
Her genial manner made her a more than
welcome visitor to the sick and depressed;
to the many of whom the dispensing of
cheer and encouragement, rather than
drugs, made the path easier for their con-
valescence and return to health.
In addition to the outpouring from the Salem
County Medical Society, the local community ex-
pressed its shock at Ellen’s tragic death: “Despite
the exacting duties of a successful professional life,
Dr. Ellen with a broadminded vision realized the
needs of civic and intellectual stimuli for the better-
ment of the people she so wholeheartedly
endeavored to serve. . . .”45 Dr. Winfield Smith died
at home on July 14, 1923, of a stroke, three years
after the death of his wife, Ellen. □
VOL. 87— NUMBER 3 MARCH 1990
223
Mary Gaston
Somerset County
On Tuesday, May 21, 1816, at 10 A. M, 9 physicians
gathered at the Public House of Daniel Sargeant.
These men made history by organizing the first
county medical society in New Jersey. They elected
Peter I. Stryker, MD, as their first president.12 Sev-
enty-five years later, in 1891, 17 of the 674 members
of the State Medical Society, elected the 18th mem-
ber of the Somerset County Medical Society, Mary
E. Gaston, MD, the first woman member.
Born in Somerville in November 1855, to Hugh M.
Gaston and Frances Mallet-Prevost Gaston, Mary
Exton was one of seven children. In a childhood
letter, Mary wrote, “I remember well various scenes
of Civil War Days — the marching boys in blue on
their way South — the summer evening where news
of the draft-riot in New York reached our town and
my father and mother sat in sombre silence and we
children talked in whispers about a ‘mob’ which to
us meant nothing at all. Then there was the thrilling
occasion when the ‘boys’ came home — the war was
over and a mile from town in the woods a whole ox
was roasting for the necessary feast, a sight we chil-
dren did not hesitate to visit before the soldiers ar-
rived.”47
Mary attended a four-room public school in
Somerville, but this did not prepare her well for
college. Upon her entrance to Vassar, Mary had to
complete a ‘‘special course to catch up to freshman.”
After two years, Mary returned home because of
family finances and became involved in a “study at
home” project of Miss Tichnor of Boston.46 4*
Mary recalled her decision to enter medical school
in an essay: “And then in 1885, from I know not
whence, came the desire to enter the medical pro-
fession. Would I have the courage to practice?
Mother thought not. I quote from a letter I received
from her at this time: ‘You are a bundle of nerves,’
she writes, ‘sensitive to every sight and sound, and
so not fitted for the profession. You would soon come
back broken in health and spirits. I would rather
have you go to Europe for a year.”47 But in 1888,
Mary received her medical degree from the Woman’s
Medical College of Pennsylvania.1016 Mary recalled
her medical school days, “I was very happy in the
Woman’s Medical College of Pennsylvania; work,
yes of course, but the table teachers and professors
of our day were always ready to help and were not
only gracious but were generally possessed with a
saving sense of humor that lightened the hard spots.
Our pleasure at graduation was dimmed for us all
by the historical snowstorm of March ’88, which
meant travel was impossible for all but nearby
friends.”47
After a 15-month internship at the New England
Hospital in Boston, Mary returned to Somerville
with her medical license issued in 1889. In the west
end of her family home, Mary opened her office, a
general practice at 18 West High Street; she was the
borough’s first woman physician.48
She was an energetic young physician; in her early
career, Mary made her night rounds on foot, no
matter what the time. She used a horse and carriage
during the day and a story is told that her father
gave her a gun for protection, but Mary always said
she was more fearful of the gun than of any harm
that could come to her on her daily rounds.
In 1891, Dr. Gaston became the first woman mem-
ber of her county society. Over the next few years,
Dr. Gaston became very involved in local medicine
and helped to found the Emergency Hospital in
Somerville on Maple Street. A history of the Emer-
gency Hospital noted that this 13-bed hospital had
money problems and was in existence only for two
years. But the community realized that a hospital
was needed and in 1900, property on East Main
Street was purchased to create a new hospital. The
Somerville Hospital had 12 beds, an operating room,
and a staff of ten physicians — including Dr. Mary
Gaston. The Hospital continued to grow: in 1903 an
ambulance was purchased and in 1908 a new wing
NEW JERSEY MEDICINE
224
Figure 15. Dr. Mary Gaston was the first woman member of our Somerset County
component, and the first woman physician in Somerville. Her portrait hangs in the
Somerville Public Library. (© Spud Grammar.)
was added; in 1925, a new 100-bed hospital was built
on Rehill Avenue; today there are 350 beds/9
Somerset County reporters submitted yearly
statements to the State Society on local activities.
Though Mary was active, her name did not appear
on any records until 1894. Dr. A.L. Stillwell, MD,
reported interesting cases in the county including
one in the practice of Dr. Gaston. “Operation was
also done by Dr. Stimson. At the time of operation,
however, there was general peritonitis, and the pa-
tient died in about eight days from sepsis.”9
Reporter J. Hervey Buchanan wrote on May 20,
1901, that Somerset County Medical Society “has to
report a year of much interest and of well -attended
and profitable meetings. The attendance has been
uniformly good, the discussions well maintained.”
He noted that Somerset Hospital had opened, with
help from Dr. Gaston, and “has seen good service,
a number of major operations having already been
performed there. The need of such an institution has
been felt for a long while, and the efforts of the
profession and the laity interested to secure it are
much to be commended.”9
Dr. Gaston retired from active medical practice in
1908 after a severe heart attack, and resigned her
membership in the Medical Society in 1911. Dr.
Gaston traveled extensively after this and devoted
herself to civic work — she brought the Public Li-
brary to Somerville in 1910 and established the
Somerville Civil League, the Red Cross Chapter of
Somerset County, and the Somerset County Anti-
Tuberculosis League.4649
Dr. Gaston did go back to active duty once, during
the flu epidemic in 1918. “A temporary hospital was
set up and she was the doctor practically in resi-
dence.”47
After a long illness, at the age of 100, Mary died
of hypostatic pneumonia, on April 19, 1956. □
VOL. 87— NUMBER 3 MARCH 1990
225
Katherine Stewart
Sussex County
Drs. Reuel Hampton and George Hopkins received
approval from the State Society to create a county
organization in May 1818. They returned to their
hometown and along with seven other physicians
tried to establish the Sussex County Medical Society
on July 14, 1818. 12 But the effort of these physicians
failed, and it wasn’t until August 1829, that four
doctors reorganized the Sussex County Medical So-
ciety. In 1943, this County Society elected its first
woman member, Katherine E. Stewart, MD.
Born on September 28, 1911, in Jacksonville,
Florida, Katherine was one of six women graduates
in the 1935 class of the University of Cincinnati
College of Medicine. She was awarded her license
from the state of Ohio that same year.1016 Katherine
completed an internship at the University of Wis-
consin Hospital, Madison, in 1935 and at River Pines
Sanatarium, Stevens Point, Wisconsin, in 1936. The
following year, Katherine married a radiologist, Dr.
Aitken, and they moved to New York."0
For the next few years, Katherine did not work in
the medical field. In 1942, Dr. Stewart completed an
internship at the Department of Internal Medicine,
Bellevue Hospital. The next year, her husband ac-
cepted a position at a New Jersey company, and
they moved to Railroad Avenue, Ogdensburg.9 A few
months later, Dr. Stewart and Dr. Aitken applied
for and received their licenses to practice in New
Jersey.
At the meeting of the Sussex County Medical So-
ciety on September 28, 1943, Dr. Stewart was in-
augurated into the Society, becoming the 32nd
member of the organization.
Dr. Stewart did not practice medicine for the next
three to four years. With the call for physicians dur-
ing the war, Katherine once again began to practice.
She was one of a small number of physicians in the
county and spent at least half of her time traveling
around the county. At that time, an office call was
one dollar and a house call was three dollars. Though
the only female member of the county society, and
one of the few physicians remaining in the state, Dr.
Figure 16. Dr. Katherine Stewart-Aitken, the
first woman physician of the Sussex County
Medical Society, now lives in Wisconsin with
her physician-husband. This photograph was
taken in 1986, after her retirement from full-
time practice.
Stewart was easily accepted by the local medical
community and felt she could always count on the
male physicians when necessary. She worked as a
family practitioner in Sussex County until 1949. 50
Dr. Stewart served as County Reporter for Sussex
from 1947 to 1948. Her reports to the State were
complete and lengthy.
She was an active participant in organized medi-
cine, as she was a member of the American Medical
Association, and a fellow of the American Board of
Internal Medicine.15
When Dr. Stewart left New Jersey in 1949 for
Madison, Wisconsin, there were 33 members in
Sussex County. Dr. Stewart became affiliated with
the University of Wisconsin Hospital. Both Dr.
Aitken and Dr. Stewart then relocated to Eau Claire,
and Dr. Stewart devoted herself to work for the de-
velopmentally disabled; she continued in this field
for the next 21 years.50
Dr. Stewart retired from active practice in 1977.
Presently, she and her husband live in Wisconsin.
She does volunteer work in the intensive care unit
for a local hospital. □
i
226
NEW JERSEY MEDICINE
Eleanor Galt
Union County
On June 7, 1869, in the Court House in Elizabeth,
15 physicians met to create the Union County Medi-
cal Society; the physicians felt they could “organize
and sustain a Society beneficial to the interests of
the profession.” Dr. Samuel Abernethy served as the
first president of this Society.9 Sixteen years later,
the Union County Medical Society elected its first
woman member, Eleanor E. Galt, MD.
Born in 1854 in Delaware County, New York,
Eleanor Galt was the daughter of Dr. Joseph Galt,
and his wife Louise.1051 As the child of a physician,
her family had enough money to educate her pri-
vately by tutors in her southern New York State
community. Eleanor attended the Woman’s Medical
College of Pennsylvania; the topic of her graduating
thesis was, “The Absorption of Fat.” And, on March
13, 1879, at noon, at Association Hall, Philadelphia,
Eleanor received her medical degree along with 19
other young women (including Sophia Presley) of
the 29th class of the Medical College. Dr. Clara
Marshall, a professor of materia medica, was the
commencement speaker; a portion of her oration was
directed to their unique situation as women phy-
sicians: “Seek and take advantage of opportunities;
despise no opening wedge, however small. Be baffled
in no rightful undertaking, however formidable.
Every circumstance comes as a helping hand, not
only to the profession, but to our sex . . . [Women
Figure 17. Dr. Eleanor Galt-Simmons, the first woman member of the Union County Medical Society, lived in
Coconut Grove, Florida, in a home built around 1916. (© D.F. Muller, courtesy of Dr. William Straight.)
VOL. 87— NUMBER 3 MARCH 1990
227
physicians] still carry the burden of a twofold re-
sponsibility: fidelity to a great cause and devotion
to the interests of a noble profession . . . The woman
of society is too often its slave. You should be wise
enough and shrewd enough to make society serve
you.”2
After graduation, Dr. Galt was a First Assistant
at the Nursery and Child’s Hospital in New York.5'
Along with five of her classmates, Eleanor worked
at the Country Branch of this Hospital in Staten
Island. Founded to offer care for infants of wet nurs-
es, the Hospital consisted of “a main hospital and
a series of fresh air children’s villages. The Country
Branch provided adult supervision, schools, religious
guidance, food, clothing, and medical care to the
children it admitted.”2 Historical files record the
words of Mary A. DuBois, the hospital director,
“Female physicians are obliged to pass as strict
examinations as men, before they graduate. With
the learning and skill which so many have already
exhibited, it is time that an earnest plea should be
made that our Public City Institutions for women
and children, should be placed under the care and
guidance of women physicians.”2
With her internship at the Nursery and Child’s
Hospital completed, Dr. Galt moved to 130 Jefferson
Avenue in Elizabeth, where she opened a private
general practice. At this time, the community had
one hospital that opened in 1877; Dr. Galt was one
of nine staff physicians in this 26-bed hospital.9
On October 8, 1884, membership for Dr. Galt was
proposed, and she was elected to the Union County
Medical Society on January 14, 1885. In 1885, the
Union County Medical Society boasted 41 members
of the 577 members of the State Society.
Seven years after she opened her medical practice,
Dr. Galt married an attorney, Captain Albion R.
Simmons. The 1892 records of the Medical Society
of New Jersey reflected this marriage by changing
the roster to read Dr. Eleanor E. Galt-Simmons. The
newlyweds resided at 1150 East Jersey Avenue,
Elizabeth; later that year, in November 1892, when
Eleanor was 37, they moved to Coconut Grove,
Florida.
Dr. Simmons remained a member of the Union
County Medical Society for 11 years; she maintained
her membership until 1896, even though she had
moved out of state in 1892.
Captain and Mrs. Doctor Simmons, as they were
known, purchased eight acres of land and built their
home on the coral bedrock. This first house burned
and they rebuilt a home on the same land. In ad-
dition, a small structure was built for Eleanor’s of-
fice.51
Coconut Grove was a young, frontier community
of 250 inhabitants when the newlyweds arrived;
there were few physicians in this area and Dr. Sim-
mons set up shop soon after arriving. She was well
received in her new hometown. Quite unknowingly,
Dr. Simmons made history again, as the first woman
physician to practice in Dade County, Florida.51 For
$1, Dr. Simmons was issued an occupational license
in 1894. The local newspaper, The Miami Metrop-
olis, published an account of her work in 1895, that
remains a part of her special history: Sam Lewis, a
wounded fugitive, was in need of medical attention.
After Dr. Simmons dressed the wounds of the man
Sam Lewis shot, Eleanor offered her services to Sam
Lewis: “She removed two bullets from his right thigh
and one from his left leg, dressed his wounds and
splinted the compound fracture of the leg. She re-
fused his request for enough chloroform to put
himself to sleep permanently. A few hours later,
wracked with pain, thirst, and hunger, Lewis sur-
rendered.”51
Memoirs of townspeople record that Doctor Sim-
mons was “a petite, blond, well-groomed person of
conservative dress and manner. Her dresses came to
her ankles; only her high buttoned shoes showing
beneath them. She probably also wore a broad-
brimmed hat. She was friendly, easy to talk to, and
walked with a quick step.” She made her medical
rounds in a road cart drawn by a single horse driven
by the Doctor or her houseboy.51
Simmons maintained an active practice in
Florida; she also participated in community affairs,
and in 1893 was elected to the Housekeeper’s Club;
she remained a member until her death. The Club’s
minutes report Dr. Galt gave lectures on health mat-
ters, including the following excerpt: “Dr. Simmons
gave a talk on sanitation in the household. She
traced the evolution of our sanitary ideas, and de-
fined the noxious and dangerous elements we have
to contend with. Her explanation of personal sani-
tation, the method of eliminating poisons from the
human system, was listened to with interest. She
emphasized the necessity of burning all materials
connected with infectious disease.”2
Dr. Simmons was elected to membership in the
Florida Medical Association in April 1898 and in
September 1903, she was a charter member of the
Dade County Medical Association.
In 1899, the local newspaper reported that Doctor
Simmons “is very sick with an old time trouble.”51
After this Eleanor never regained her former
strength, but continued to practice as a physician
for the Lake Placid School and the Adirondack-
Florida School.
By November 1908, Eleanor was a widow, and she
moved to Miami to be closer to her physician. She
died of tuberculosis of the brain at the age of 55 on
February 2, 1909. 6 The Miami Metropolis noted the
townspeople “came in numbers” to the First Presby-
terian Church of Miami to pay their respects.51 □
228
NEW JERSEY MEDICINE
Doreen Sheffield
Warren County
On November 8, 1825, the administrators of the
Medical Society of New Jersey agreed to allow for
a county society in Warren. Under the leadership of
Dr. Jabez Gwinnup, ten physicians organized in
February 1826, at the home of John P. Ribble. The
county physicians, though, did not elect a woman
member until 1950, when Doreen R.C. Sheffield,
MD, was accepted into the organization.9
Doreen Rippon Corke was born in Winnipeg,
Manitoba, Canada, on March 29, 1907; she had two
sisters and one brother. Doreen completed her
undergraduate education at Selkirk Collegiate In-
stitute, Manitoba, in 1922, and at the University of
Manitoba in 1924. 54 She received her medical degree
from the University of Manitoba School of Medicine,
Canada, in May 1929. School records noted she was
“creditable” throughout her course work. She com-
pleted the required one-year internship at Children’s
and General Hospitals, Manitoba.52
Dr. Corke moved to Philadelphia, Pennsylvania,
in 1930 after accepting a staff position at the
Woman’s Hospital. Soon after, she moved to New
York to intern at Beekman Street Hospital until
October 1931. 15 Doreen then was employed as an
intern at St. Mary’s Hospital for Children in 1932,
and received her New York license in 1933. After
that position, she was on the staff of Seaside Hospi-
tal, Staten Island, from June 1933 to September
1933 and lived in Brooklyn, New York.
In May 1945, Dr. Corke moved to Hobart, New
York, and that was her address until she moved to
Baltimore, Maryland, in April 1946. 15
In 1946, Doreen married William H. Sheffield;
they had one child, Anne. The following year, the
Sheffields moved to Oxford, New Jersey, and in 1948
Doreen was awarded her New Jersey license.15
The 34 members of the Warren County Medical
Society accepted Dr. Sheffield’s application for
membership, and she was listed as a member from
1950 until 1953. The Warren County Reporter did
not list her name as delivering papers or attending
any county society meetings.
In addition to her membership with the Medical
Society, Dr. Sheffield was a member of the Ameri-
can Medical Association; she maintained her mem-
bership until 1961.
Dr. Sheffield moved again in 1954, to Plainfield,
and in 1956, she moved to Rumson; in 1957, her
address was listed as Ridgewood but she noted “she
was no longer in practice.”15
On February 2, 1959, Dr. Sheffield reported to the
AMA her move to Cooperstown, New York. She died
of cancer on December 6, 1961. 15,52 □
Conclusion
Twenty physicians redefined the social and pro-
fessional roles of 19th and 20th century women in
New Jersey. These pioneers were “comfortable with
the idea of studying medicine,”2 and they were good
at it. They integrated their chosen field of medicine
and the real world, for they “had a special concern
for family and preventive medicine.”2
It was a long tough fight: “The regular medical
professional objected on many levels to the entrance
of woman into its ranks. In the first place, the vast
majority of doctors were traditionalists who
subscribed to the cult of domesticity with the same
intense tenacity as their nonmedical brethren. . . .
Other physicians cited woman’s inferior intellect,
her passivity of mind, her physical weakness, and
her tendency toward hysteria. . . . More subtle and
more insidious was the feat that an influx of women
would alter the image of the profession by feminizing
it in an unacceptable way.”2
Yet, these 20 women and others like them per-
severed. They found their places in medicine and
medicine found places for them. What is most im-
pressive is that these women accomplished so much.
They were universally accepted in their New Jersey
communities by patients and eventually were ac-
cepted by male colleagues. Only one woman’s nomi-
nation into a county society was the cause of dis-
cussion, and only one county reporter even men-
tioned the fact that a woman finally had been ad-
mitted into a county medical society.53'57
These biographical materials prove that these
women, knowingly or unknowingly, furthered the
cause of equal rights. Quietly and unassumingly, 20
women physicians in New Jersey made history. ■
VOL. 87— NUMBER 3 MARCH 1990
229
References
1. The Woman’s Book, Volume 1. New York, NY,
Charles Scribner’s Sons, 1894, pp. 48-51.
2. Abram RJ: Women Doctors in America, 1835-1920:
Send Us a Lady Physician. New York, NY, W.W. Norton
& Company, 1985.
3. Marks G, Beatty WK: Women in White. New York,
NY, Charles Scribner’s Sons, 1972.
4. Annual Report of the New York Infirmary: The First
Hundred Years. New York, NY, 1954, pp. 19-26.
5. Lovejoy EP: Women Doctors of the World. New
York, NY, MacMillan Co., 1957.
6. Transactions of the Annual Meetings of the Alumnae
Association of the Woman’s Medical College of Penn-
sylvania (Simmons, 1909; Hallowed, 1910; Smith, 1920;
Marsh, 1921; Haines, 1924; Clement, 1925).
7. Personal communication: U. Berkley Ellis, executive
director, Montgomery County Medical Society, Septem-
ber 11, 1989.
8. Transactions, State Medical Society of Kansas, 1872,
pp. 166-167.
9. Medical Society of New Jersey: Transactions and
The Journal of the Medical Society of New Jersey,
1776-1956. Trenton, NJ.
10. Brodman Index: New Jersey Women Physicians,
1886-1982. March 1989. UMDNJ-George F. Smith Li-
brary, Newark.
11. Heston AM: Absegami: Annuals of Eyren Haven
and Atlantic City, 1609-1904, p. 232.
12. Rogers F, Sayre AR: The Healing Art. Trenton, NJ,
Medical Society of New Jersey, 1966.
13. The First Hundred Years of the Bergen County
Medical Society, 1854-1954.
14. Van Horn A: Van Horn Family of Bergen County,
1657-1927.
15. AMA Records and Archives. Chicago, IL, 1989.
16. Personal correspondence, Mrs. Jean Baber, Phila-
delphia, PA.
17. Obituary, Carrie Helen Van Horne, MD, personal
papers, Dr. Felix H. Vaun, UMDNJ-George F. Smith Li-
brary, Newark.
18. Last will and testament, Caroline H. Van Horne,
January 20, 1914.
19. 1910 Federal Census, Metzer Family.
20. Personal correspondence, Patricia Ann Metzer, No-
vember 10, 1989.
21. Biographical Review: Sketches of Leading Citizens
of Burlington and Camden Counties. Boston, MA, Bio-
graphic Review Publishing Co., 1947, pp. 169-170.
22. Teffeau C: Sophia Presley, MD: The spinster who
struggled seven years against bias of male doctors. Bull
Camden Cty His Soc, May 1985, pp. 37-45.
23. Stevens LT: History of Cape May County, New
Jersey. Cape May City, NJ, 1897, p. 397.
24. Way J: Medical men of early times in Cape May.
Cape May County Magazine History Genealogy 1:1-17,
1934.
25. Butler MF: Minutes of the ’49 Annual Meeting,
Woman’s Medical College of Pennsylvania, pp. 14-15.
26. Meeker ER: New Jersey: Historical, Commercial,
and Industrial Review. Elizabeth, NJ, Commonwealth
Publishing Co., 1906.
27. Superintendent’s Report: Home of the Feeble-
Minded, 1889 and 1901.
28. Fairault MN: Training and Treatment of the
Feeble-Minded and of the Epileptic. Journal of Psycho-
Asthenics, 1899, p. 203.
29. Stone FS: Racine, Belle City of the Lakes. S.J.
Clarke Publishing Co., Chicago, IL, 1916, pp. 248-249.
30. Newark Evening News, 1924.
31. Gloucester County Democrat, January 29, 1925,
Woodbury, NJ.
32. Correspondence, Millv Riley, 1989. LlMDNJ-George
F. Smith Library, Newark.
33. Personal communication, Mrs. Clark, December 11,
1989.
34. University of Buffalo Medical School Archives,
1929.
35. Mercer County Medical Society, Trenton, NJ, 1914.
36. Acton JN: Bradway Families. Salem, NJ, Salem
County Historical Society, 1978.
37. Personal communication, Johns Hopkins Medical
School, 1989.
38. Protestant Missions, 1924, P.F. Mission Society.
39. Personal communication, Cambria County Medical
Society, Mr. Michael Kohler, October 1989.
40. Asbury Park Journal, October 20, 1903; October 30,
1903, p. 1.
41. City Directories, Paterson, NJ, 1875-1886.
42. Thron LE, Clark GA: Greater Paterson.
43. Ononadagan 1902. Syracuse University, Syracuse,
NY, 1902.
44. Dr. Marie Louise Chard. Women 's Medical Journal,
New York Academy of Medicine, New York, NY. April
1938, pp. 114-115.
45. The death of Dr. Ellen B. Smith. The Salem Stan-
dard, May 19, 1920.
46. Biographical, Genealogical, and Descriptive History
of the First Congressional District of New Jersey, Volume
II. Lewis Publishing Company, New York, NY, 1900, pp.
566-567.
47. Personal communication, Evelyn G. Van der Veer,
September 22, 1989.
48. Women who pioneered. Somerset Press Newspaper,
September 8, 1988.
49. Sanford ME: A history of the medical staff at
Somerset Hospital. Somerset Medical Center, January
1989.
50. Personal communication, Dr. Katherine E.S.
Aitken, December 1989.
51. Straight WM: The lady doctor of the grove. J
Florida Med Assoc 56:615-621, 1969.
52. Personal communication, Dr. Audrey M. Kerr, Uni-
versity of Manitoba, August 28, 1989.
53. Morantz-Sanchez RM: Sympathy and Science.
New York, NY, Oxford University Press, 1985.
54. Walsh MR: Doctors Wanted: No Women Need
Apply. New Haven, CT, Yale University Press, 1977.
55. Cowen D: Medicine and Health in New Jersey.
Princeton, NJ, Van Nostrand Co., 1964.
56. Morantz RM, Pomerleau CS: In Her Own Words,
GP, Westport, CT, 1982.
57. Levin BS: Women and Medicine. Metuchen, NJ,
Scarecrow Press, 1980.
230
NEW JERSEY MEDICINE
HOUSING APPLICATION
224th ANNUAL MEETING
MEDICAL SOCIETY OF NEW JERSEY
MAY 6-9, 1990
Select the hotel of your choice. Mail the entire form with one night’s deposit to that hotel.
THE SANDS HOTEL, CASINO & COUNTRY CLUB (Headquarters Hotel)
INDIANA AVE. AT BRIGHTON PARK, P.O. BOX 28, ATLANTIC CITY, NJ 08404
RESERVATION DEPARTMENT 1-800-257-8580
(Please Print)
Name__
Address
City State Zip
Home Phone Business Phone
Sharing With
Date of Arrival Time
Date of Departure Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the SANDS or complete the following:
American Express No. Expiration Date
SCHEDULE OF RATES SUBJECT TO 12% TAX
□ SINGLE $75.00 □ One-Bedroom Suite $225.00 □ Two-Bedroom Suite $300.00
□ DOUBLE $75.00 (Reservations must be received prior to April 6, 1990)
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
CLARIDGE CASINO HOTEL
INDIANA AVE. AT THE BOARDWALK, P.O. 448, ATLANTIC CITY, NJ 08404
RESERVATION DEPARTMENT (609) 340-3434
NJ ONLY 1-800-582-7676
(Please Print)
Name
Address
City State Zip
Home Phone Business Phone
Sharing With
Date of Arrival Time
Date of Departure Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the CLARIDGE or complete the following:
Card # Type Exp. Date
SCHEDULE OF RATES SUBJECT TO 12% TAX
D SINGLE $75.00 □ One-Bedroom Suite $225.00 D Two-Bedroom Suite $300.00
□ DOUBLE $75.00 (Reservations must be received prior to April 5, 1990)
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
VOL. 87— NUMBER 3 MARCH 1990
231
NEW JERSEY MEDICINE
itic City Convention Center
ill
NOTEBOOK
■ TRUSTEES’ REPORT*
A regular meeting of the Board
of Trustees was held on January
21, 1990, at Society headquarters.
Detailed minutes are on file with
the secretary of your county so-
ciety. A summary of significant ac-
tions follows:
Report of the President . . .
(1) Membership Recruitment
. . . Congratulated Ocean County
Medical Society on the success of
their recruitment efforts.
(2) Physicians’ Health Program
. . . Encouraged county societies to
invite Dr. Canavan, medical direc-
tor of the program, to meetings.
(3) Meeting of County Medical
Society Executives . . . Com-
mented on the following: the
“Capitol Commentary” mailing;
direct mailings to members when
there is a need; suggestion that
leadership conference be held
twice a year; development of a sys-
tem in which MSNJ would per-
form the billing function for coun-
ties; need for format by which
MSNJ can respond directly to re-
quests for membership; and advice
on computer purchasing for county
societies.
(4) Pennsylvania Blue Shield
Medicare Program . . . Noted
that Mr. Joseph Lucci is available
to discuss Medicare management
with county societies.
(5) JEMPAC . . . Expressed ap-
preciation for the 100 percent sup-
port of JEMPAC by Board mem-
bers and the AMA delegation, and
requested all county societies urge
executive members to join JEM-
PAC. Also, approved the slate of
JEMPAC officers proposed by the
Nominating Committee:
Harry M. Carnes, MD
Chairman
Gabriel F. Sciallis, MD
Vice-Chairman
Edward A. Schauer, MD
Secretary
Bartholomew R. D’Ascoli, MD
Treasurer
Joseph A. Riggs, MD
Member-at-Large
William E. Ryan, MD
Member-at-Large
(6) Governor’s Insurance Plan
. . . Noted Mr. Maressa’s expla-
nation that Governor Florio in-
structed his staff to develop a
proposal to abolish the Joint
Underwriters Association (JUA);
the Society already has instituted
action in opposition.
(7) AMA Hospital Medical Staff
Section . . . Endorsed the can-
didacy of Doctor Robert J.
Weierman as a candidate for sec-
retary of the AMA Hospital Medi-
cal Staff Section.
(8) Portrait Gallery for Fellows
. . . Approved the concept of
providing an appropriate area of
the headquarters building to
exhibit portraits of past presi-
dents.
(9) AMA Leadership Conference
. . . Noted that Doctors Costabile,
Ryan, Formica, Franzoni, Carnes,
Ratner, and Restivo are assigned
to attend the conference; Drs.
Blome, Iacuzzo, and Redo, young
physicians, were invited to go, as
well as Edith Goldie, student
member of the Board.
(10) Medicare Provider 800 Line
. . . Noted that the 800 line will be
continued.
(11) NJ Academy of Physicians
. . . Congratulated Dr. Ralph J.
Fioretti on being named physician
of the year by the Academy.
(12) NJ Association of Medical
Specialty Societies . . . Con-
gratulated Dr. George Neumair as
president of the Association.
(13) State Department of Health
. . . Noted that Leah Z. Ziskin,
MD, is the acting commissioner of
health and a member of MSNJ.
(14) Medicare Reimbursement
on Unassigned Claims . . . Noted
that the AMA delegation will be
requested to develop an ap-
propriate resolution for introduc-
tion to the AMA expressing the So-
ciety’s objection to the new re-
quirement imposed on physicians
under the Medicare law. Also,
agreed to send a letter to New Jer-
sey congressmen concerning the
224th ANNUAL MEETING
MEDICAL SOCIETY OF NEW JERSEY
May 6-9, 1990
The Sands Hotel, Casino & Country Club
Atlantic City
Claridge Casino Hotel
Atlantic City
VOL. 87— NUMBER 3 MARCH 1990
233
objection of physicians to the new
Medicare law requiring them to
complete and mail insurance forms
to the carrier for Medicare pa-
tients, and the possible effect it
could have in limited accessibility
to care for some patients.
Report of Executive Director . . .
(1) MSNJ Paid Membership . . .
Noted paid membership to be
7,438; and Mr. Maressa will
prepare demographic information
on the membership for a future
meeting.
(2) Legislation . . . Noted the re-
vised medical waste registration
fee schedule:
Less than 50 lbs. per year . $100
50 to 200 lbs. per year $300
Over 200-300 lbs. per year . $500
Over 300-1,000 lbs.
per year $1000
Over 1,000 lbs. per year ... $3500
Also, noted that an attempt will be
made through litigation to reach a
negotiated compromise with the
Department of Environmental
Protection whereby a physician
with multiple office sites would be
considered as one registrant, re-
gardless of the number of sites, and
the aggregated amount of waste
would determine the fee. And,
noted S-2936 (medical licensing re-
form) and S-3867 represent vic-
tories for MSNJ, and the issue of
membership recruitment in-
tensification was referred to the
Council on Public Relations.
(3) Litigation . . . Noted the fol-
lowing: Jasper Jackson is the act-
ing commissioner of insurance;
Kenneth Merin was appointed to
the State Commission of Investiga-
tion; briefs for the appeal were
filed and accepted in the case of
MSNJ and the State Board of
Physical Therapy; and active argu-
ment in the case of PRO versus
MSNJ appears likely in June 1990.
(4) Pronouncement of Death . . .
Asked members to review the
reproposal Rule N.J.A.C.
13:35-6.1, Pronouncement of
Death, and mail comments to the
executive director.
UMDNJ Report . . . Heard com-
ments on the following from
Stanley S. Bergen, Jr, MD: can-
didacy of Doctor W. Douglas Skel-
ton, provost for medical affairs and
dean of Mercer University School
of Medicine, Macon, Georgia, for
the AMA Section on Medical
Schools; University Day on Janu-
ary 24, 1990; appointments of
Michael S. Katz to the National
Advisory Committee on Student
Financial Assistance, Doctor Eric
Munoz to the Prospective Pay-
ment Assessment Commission,
and Doctor Dominick DePaola as
dean of all United States dental
schools; importance of strategic
planning; slight increase in medi-
cal school applications; and MSNJ
support of the Foundation.
State Board of Medical Exam-
iners . . . Heard comments on the
following from Michael B.
Grossman, DO . . . surgical assis-
tant rule; Board of Chiropractic
Examiners will go into effect on
February 10; reproposed pro-
nouncement of death rule estab-
lishing a working definition of “at-
tending physician” and clear-cut
guidelines for moving the body;
availability of speaker’s bureau;
complexity of S-2936; reopening of
search for medical director; and
position that postoperative care, in
general, is the duty of the surgeon,
and to give responsibility for that
care to a health care provider not
equally trained is inappropriate.
NJ Hospital Association . . .
Heard comments on the following
from Louis Seibetta: Blue Cross/
Blue Shield rates; mortality data
from the Health Care Financing
Administration; and the fact that
Medicare payments have not kept
pace with hospital expenditures.
Committee on Medicaid . . . Ap-
proved the following:
That the Medical Society of New Jer-
sey seek reasonable reimbursement for
physicians under the Medicaid pro-
gram.
Committee on Membership Ser-
vices . . . Noted that the Peer Re-
view Organization Defense Plan
will be explained in an upcoming
issue of NEW JERSEY MEDI-
CINE.
Task Force on Uncompensated
Care for Physicians . . . Ap-
proved the following:
That the Task Force be renamed the
Task Force on Patient Care for the
Under-Insured.
Committee on Utilization Review
. . . Carried the following amended
recommendation:
That a questionnaire be sent to a com-
puter selected sample of 1,000 mem-
bers of MSNJ, who in their normal
practice, admit patients to the hospi-
tal.
New Business . . . Noted that the
Nominating Committee met in an
all-day session on January 17,
1990, and interviewed candidates
for all elected positions. □
■■UMDNJ NOTES**
The University of Medicine and
Dentistry of New Jersey (UMDNJ)
is expanding its southern New Jer-
sey urban and community affairs
effort with a new division to serve
Camden, Stratford, Atlantic City,
and other urban areas. Thomas R.
Jones is director of urban and com-
munity relations for this region. He
will be developing programs to
strengthen ties between UMDNJ
and southern New Jersey resi-
dents, businesses, and munici-
palities.
The National Institutes of
Health (NIH) has awarded a five-
year $2.6 million grant to Dr.
Sarah Schefer to continue her re-
search on two rare, often fatal, dis-
eases that cause atherosclerosis.
Dr. Schefer, professor of medicine
at UMDNJ-New Jersey Medical
School, is studying inherited de-
fects in the body’s ability to turn
excess cholesterol into bile acids,
that are used in digestion. The de-
234
NEW JERSEY MEDICINE
fects cause lipid storage diseases
that can be so severe a teenage vic-
tim’s arteries can look like those of
an 80-year-old. While the diseases
are rare, affecting only about 300
people worldwide, Dr. Schefer’s re-
search could lead to better treat-
ment for atherosclerosis and other
cholesterol-related ailments that
affect a broad population.
New Jersey’s first compre-
hensive urinary incontinence treat-
ment program has been opened at
the Center for Aging at UMDNJ-
School of Osteopathic Medicine,
Stratford. The program is one of a
few nationally that treats incon-
tinence with the help of com-
puters, exercise, and diet, and,
when necessary, drugs and surgery.
UMDNJ-New Jersey Dental
School staff are researching the
possibility that advanced tooth
and gum disease may be an early
warning sign of AIDS. Dr. Patricia
Murray, associate professor of
periodontics, is studying drug-
abuse patients who have AIDS and
are receiving dental care in the
school’s Special Services Clinic. In
similar studies at the University of
California at San Francisco School
of Dentistry, Dr. Murray found at
least 30 percent of the homosexual
HIV-positive patients had ad-
vanced periodontal disease. The
type of periodontal disease found
in HIV-positive patients is dif-
ferent from that found in the gen-
eral population because it is a
faster moving condition, generally
accompanied by oral lesions on the
mouth within the first two weeks.
If left untreated, periodontal dis-
ease can lead to infection that
could prove fatal to AIDS patients
whose immune systems have been
damaged by the disease. Symp-
toms of advanced periodontal dis-
ease include chronic pain originat-
ing from the jaw, exaggerated gum
recession, and bone disintegration,
resulting in teeth loss. Dr. Murray
found that by removing the dead
tissue, and irrigating the gums
with antiseptics and antibiotics,
infection can be eliminated. □
Stanley S. Bergen, Jr, MD
■HMSNJ AUXILIARY ■■
AMA Auxiliary Leadership Con-
fluence II, held in Chicago last
month, drew 300 county presi-
dents-elect, national officers and
committee members, and state
presidents and presidents-elect.
The three-day intensive learning
conference, designed to train aux-
iliary leaders at all levels of the
organization, included plenary
sessions on managing auxiliaries,
training leaders, and exploring
health issues.
Those attending from New Jer-
sey gave Confluence rave reviews.
They were particularly impressed
1990 MSNJ ANNUAL MEETING
Saturday, May 5, 1990
3:30 p.m. Board of Trustees’ Meeting
7:00 p.m. Officers’ Cocktail Reception and Dinner
Sunday, May 6, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
10:00 a.m. Educational Program
11:00 a.m. Exhibits Open
1:00 p.m. House of Delegates
3:30 p.m. Reference Committee Meetings
Monday, May 7, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates (Election)
12:00 noon Golden Merit Award Ceremony and Reception
1:00 p.m. Professional Liability Program (MIIENJ)
2:45 p.m. Reference Committee Meetings
5:00 p.m. JEMPAC Political Forum
5:45 p.m. JEMPAC Wine and Cheese Reception
6:30 p.m. Somerset County Medical Society
Tuesday, May 8, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates
1 :30 p.m. House of Delegates
2:00 p.m. Exhibits Close
6:30 p.m. Inaugural Reception and Dinner
Wednesday, May 9, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. General Session
1:00 p.m. Board of Trustees’ Meeting
VOL. 87— NUMBER 3 MARCH 1990
235
with the quality of the events: the
expert speakers, the specific
nature of the topics discussed, and
the broad spectrum of material
presented. Consultation sessions
focused on how to appoint commit-
tees, how to plan projects and pro-
grams, how to budget, and how to
establish yearly goals. AMA and
auxiliary representatives also high-
lighted cooperative efforts between
the medical societies and aux-
iliaries. A special session dealt
with the problem of impairment
and well-being within the medical
community. In addition, the direc-
tors of the AMA Division of Legis-
lative Activities and the AMA De-
partment of Congressional Affairs
gave updates on legislative issues.
Finally, a wide range of adoles-
cent health issues was explored, in-
cluding the merits of anti-drug
programs in educating and treat-
ing teens and approaches appro-
priate in teaching young people
refusal skills. Also on the agenda
were breakout sessions on teenage
pregnancy, suicide, alcohol addic-
tion, and HIV/AIDS. A representa-
tive of the AMA Youth HIV Edu-
cation Project suggested ways for
involvement in the AMA project.
For MSNJA participants, the
success of Confluence was due not
only to the plethora of information,
but to the stimulating encounters
with other knowledgeable and
enthusiastic physicians’ spouses.
Most importantly, the meetings
acted as catalysts for renewing
commitments to support projects
and charities that both improve
the lives of people in the communi-
ty and enhance the public’s image
of medicine and the medical fam-
ily. □ Marion H. Geib
HH ERRATA
The first sentence in the final
paragraph of the article entitled,
“Cutaneous Malignant Melan-
oma,” by Drs. Nwiloh, Sussman,
Tambouret, and Dardik (February
1990) was incorrect. The para-
graph should read: The results of
treatment of advanced MM re-
mains dismal, with limited pallia-
tion obtained from chemotherapy,
radiotherapy, immunotherapy,
and hormonal therapy. In this
series from Englewood Hospital,
mean survival for stages II and III
was 12.5 and 1.5 months, respec-
tively. □
HH PLACEMENT FILE ■■
The following physicians have
written to the Executive Offices of
MSNJ seeking information on
possible opportunities for practice
in New Jersey. The information
listed below has been supplied by
the physicians. If you are inter-
ested in any further information,
we suggest you make inquiries
directly to them.
CARDIOLOGY
Fredric Gerewitz, MD, 125 Montgom-
ery Ave., Bala Cynwyd, PA 19004.
SUNY-Downstate 1984. Board eligi-
ble. Group or partnership. Available
July 1990.
GASTROENTEROLOGY
Eric Avezzano, MD, 2510 B.S. Walter
Reed Dr., Arlington, VA 22206. SUNY-
Stony Brook 1985. Board certified
(IM); board eligible (GI). Group, part-
nership, solo. Available July 1990.
GENERAL PRACTICE
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Available.
Randi Silverbrook, DO, 3024 Wistar
Ct., Bensalem, PA 19020. College of
Osteopathic Medicine 1985. Partner-
ship or group. July 1990.
INTERNAL MEDICINE
David D. Gross, MD, 1045 Liberty St.,
Apt. 1, Trenton, NJ 08611. St.
George’s University (Grenada) 1987.
Board eligible. Available August 1990.
Suresh Reddy, MD, 3301 Cobblestone
Circ., #6, Waterloo, IA 50703.
Kakatiya (India) 1980. Board certified.
Board eligible (GASTRO). Group,
partnership, solo. Available.
Himanshu Shah, MD, 71 Louis St.,
New Brunswick, NJ 08901. UMDNJ
1988. Part-time position. Available.
NUCLEAR MEDICINE
Robert W. Cifers, MD, 26 Somers
Ave., Seaville, NJ 08230. Ohio State
1983. Board eligible. Available.
PATHOLOGY
Ruth Kreitzer-Richards, MD, 5470
Mosholu Ave., Riverdale, NY 10471.
Guadalajara 1983. Board certified.
Available July 1990.
Judith Vople, MD, 106 Orlando Blvd.,
Toms River, NJ 08757. UMDNJ 1985.
Board eligible. Group or hospital-
based. Available July 1990.
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
236
NEW JERSEY MEDICINE
Hahnemann University
Department of Medicine
WEDNESDAYS GRAND ROUNDS
MARCH 1990
March 7, 1990
IMMUNE INTERVENTION IN TYPE I DIABETES
MELLITUS
Jay S. Skylar, M.D.
Professor of Medicine
Director, Diabetes Mellltus
University of Miami
Miami, FL
March 14, 1990
COPD: PATHOGENESIS AND TREATMENT
ADVANCES
Mark J. Utell. M.D.
Professor of Medicine and Toxicology
University of Rochester
Rochester, NY
March 21,1990
CLINICAL PHARMACOLOGY
Vincent J. Zarro, M.D., Ph.D.
Associate Professor of Pharmacology & Medicine
Director, Division of Clinical Pharmacology
Hahnemann University
March 28. 1990
DERMATOLOGIC TREATMENT WITH RETINOIDS
AND CYCLOSPORINE
Richard L. Splelvogel, M.D.
Professor of Medicine and Dermatology
Director, Division of Dermatology
Hahnemann University
APRIL 1990
April 4, 1990
CARDIAC ELECTROPHYSIOLOGY: EVOLVING
DIAGNOSTIC AND THERAPEUTIC MODALITIES
John D. Fisher, M.D.
Professor of Medicine
Director, Cardiac Arrhythmia Service
Acting Director, Division of Cardiology
Monteflore Medical Center
New York, NY
MARCH 28, 1990
Cyclosporine and Systemic Retinoids:
Therapeutic Options
GUEST FACULTY
Cynthia A. Guzzo, M.D.
Assistant Professor of Dermatology
Unlv. of Pennsylvania, Dept, of Pathology
Philadelphia, PA
Henry H. Roenlgk, Jr., M.D.
Professor of Dermatology
Chairman, Dept, of Dermatology
Northwestern Unlv., Chicago, IL
HAHNEMANN UNIVERSITY FACULTY
Gary R. Kantor, M.D.
Richard L. Splevogel, M.D. (Course Director)
Eric C. Vonderheld, M.D.
APRIL 25, 1990
Infectious Diseases: Treatment of Difficulty and
Opportunistic Fungal Infections
GUEST FACULTY
8:30 A.M.-9:30 A.M.
March-May 1990
April 11, 1990
MEDICAL MANAGEMENT OF GALLSTONE
DISEASE
Hans Fromm, M.D.
Professor of Medicine
Director, Division of Gastroenterology
The George Washington University
Washington, DC
April 18, 1990
ENDOCRINOLOGY AND METABOLISM: RECENT
ADVANCES
Leslie I. Rose, M.D.
Professor of Medicine
Director, Division of Endocrinology and
Metabolism
Hahnemann University
Jeffrey L. Miller, M.D.
Associate Professor of Medicine
Division of Endocrinology and Metabolism
Hahnemann University
April 25, 1990
PROSTHETIC VALVE ENDOCARDITIS
William E. Dlsmukes, M.D.
Professor & Vice Chairman for Educational
Programs
Department of Medicine
University of Alabama
Birmingham, AL
MAY 1990
May 2, 1990
VENOUS THROMBOEMBOLIC DISORDERS:
UPDATE 1990
John C. Hoak, M.D.
Director, Division of Blood Diseases and
Resources
National Heart, Lung and Blood Institute
National Institutes of Health
Bethesda, MD
WEDNESDAYS
MEDICAL SEMINAR SERIES —
8:30 A.M.-3:00 P.M.
William E. Dlsmukes, M.D.
Professor and Vice-Chairman
Department of Medicine
Unlv. of Alabama School of Medicine
David J. Drutz, M.D.
Adjunct Professor of Medicine
Unlv. of Pennsylvania School of Medicine
Adjunct Professor of Microbiology & Immunology
Temple University Medical School
Thomas J. Walsh, M.D.
National Cancer Institute
National Institutes of Health
HAHNEMANN UNIVERSITY FACULTY
Emily A. Blumberg, M.D.
Abdolghader Molavl, M.D. (Course Director)
Craig A. Wood, M.D.
MAY 9, 1990
The Age of Immunosuppressive Therapy and
Organ Transplantation
GUEST FACULTY
May 9, 1990
IMMUNE MECHANISMS: BREAKTHROUGHS IN
IMMUNOSUPPRESSION
George H. Hltchlngs, Jr., Ph.D., D.Sc.
Nobel Prize Winner 1988 In Medicine and
Physiology
Duke University
Durham, NC
Adjunct Professor of Pharmacology
University of North Carolina
Chapel Hill, NC
Scientist Emeritus
Burroughs Wellcome Co.
Terry Strom, M.D.
Professor of Medicine
Harvard Medical School
Director of Clinical Immunology
Beth Israel Hospital
Boston, MA
May 16, 1990
INFECTIOUS DISEASES: NEWEST ADVANCES
Abdolghader Molavl, M.D.
Associate Professor of Medicine & Surgery
Director, Division of Infectious Diseases
Hahnemann University
May 23, 1990
"NEW FASHION" CLINICAL PATHOLOGIC
CONFERENCE
Kenneth Cohen, M.D.
Associate Professor of Medicine
Director, Internal Medicine Residency Program
Hahnemann University
May 30, 1990
"OLD FASHION” CLINICAL PATHOLOGIC
CONFERENCE
Eugene Coodley, M.D.
Professor of Medicine
University of California, Irvine
Director of Geriatric Medicine
Longbeach VA Hospital
Longbeach, CA
George H. Hltchlngs, Jr., Ph D., D.Sc.
Nobel Laureate, 1988, Medicine and Physiology
Adjunct Professor of Pharmacology &
Experimental Medicine
Duke University
Adjunct Professor of Pharmacology
University of North Carolina
Scientist Emeritus, Burroughs Wellcome Co.
Terry Strom, M.D.
Professor of Medicine
Harvard Medical School
Director of Clinical Immunology
Beth Israel Hospital
President
American Society of Immunology
HAHNEMANN UNIVERSITY FACULTY
Joseph H. Brezln, M.D.
Isadore Brodsky, M.D.
Robert Chvala, M.D.
Farokh Samlnl, M.D.
Allan B. Schwartz, M.D. (Course Director)
Presented by:
William S. Frankl, M.D.
Professor of Medicine and Chairman
Department of Medicine
Allan B. Schwartz, M.D.
Professor of Medicine and
Director, Continuing Medical Education
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd Floor — College Bldg.
Hahnemann University
15th Street Entrance
15th and Vine Streets
Philadelphia. PA
We wish to acknowledge educational support from
E.R. Squibb & Sons
Merck, Sharpe & Dohme
Burroughs Wellcome & Co
Squibb-Novo
Sandoz
Roche
CIBA-Geigy
Approved for CME credits through the Office of Continuing Education, Hahnemann University
For further information: (215) 448-8263
VOL. 87— NUMBER 3 MARCH 1990
237
ALLERGY
May
7- Immunology and the Visual
8 System
8 A.M.-5 P.M.— Bally’s Grand
Hotel, Atlantic City
(UMDNJ)
ANESTHESIOLOGY
May
15 Meeting
6-9 P.M. — Ramada Inn, Clark
(New Jersey State Society of
Anesthesiologists)
CARDIOLOGY
April
4 Esophageal Causes of
Chest Pain
1:30-2:30 P.M. — Rutgers
Community Health Plan,
New Brunswick
(Rutgers Community Health
Plan)
18 Silent Ischemia
1:30-2:30 P.M. — Rutgers
Community Health Plan,
New Brunswick
(RCHP)
DERMATOLOGY
April
18 Robert Wood Johnson
Medical School
Dermatological Conferences
6-9 P.M. — Rutgers Community
Health Plan, US #1,
New Brunswick
(UMDNJ)
May
16 Robert Wood Johnson
Medical School
Dermatological Conferences
6-9 P.M. — Rutgers Community
Health Plan, US #1,
New Brunswick
(UMDNJ)
24 Update on Superficial Fungal
Infections
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
INFECTIOUS DISEASE
April
4 Counseling and Testing for HIV
Infection
11:30 A. M. -12:30 P.M. —Rahway
Hospital, Rahway
( AMNJ and NJDOH)
20 Clinical Management of HIV
Infection
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ and NJDOH)
21 Common Infections
8:30-9:30 A.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital)
May
2 Lyme Disease
10:30-11:30 A. M.— St. Mary’s
Hospital, Passaic
(AMNJ and NJDOH)
9 Proper Use of Antibiotics
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ and NJDOH)
22 Clinical Management of HIV
Infection
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
30 Lyme Disease
10:30-11:30 A.M. — Christ
Hospital, Jersey City
(AMNJ and NJDOH)
MEDICINE
April
3 Fourth Annual Internal
17 Medicine and Board Review
24 5:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
4 Living Wills
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
4 Medical Lecture Series
11 10:30-11:30 A.M. —Christ
18 Hospital, Jersey City
25 ( Christ Hospital)
4 Internal Medicine
1 1 Review Course
18 4-7 P.M. — University Hospital,
25 New Brunswick
(AMNJ and UMDNJ)
4 Review Course in Internal
18 Medicine
25 11 A.M. -1P.M. — Bayonne
Hospital, Bayonne
(Bayonne Hospital)
5 Growth Factor
19 Molecular Mechanisms Series
26 4-6 P.M. — Coriell Institute for
Medical Research, Camden
( Coriell Institute)
5 Immunology
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
6 Burns
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
6 Continuing Medical
13 Education Program
20 12 Noon-1 P.M. — South Jersey
27 Hospital System, Bridgeton
(South Jersey Hospital System)
6 Alcohol and Drug Dependencies
8:30 A.M. -4:15 P.M. — Holiday Inn,
Jamesburg
(New Beginnings)
10 Renal Biopsy Conferences
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
11 Dialogues in Critical Medical
Decisions
7:30-9 P.M. — Englewood Hospital,
Englewood
(Englewood Hospital)
1 1 Prescription Drug Abuse
7-9 P.M. — The Still Restaurant,
Andover
(Hackettstown Community
Hospital)
1 1 Prevention of Lower Extremity
Amputations
9-10 A.M. — Somerset Medical
Center, Somerville
(AMNJ and NJDOH)
12 Advances in Fetal Medicine
7:45-9 P.M. — Memorial Hospital
of Burlington County,
Mount Holly
...
238
NEW JERSEY MEDICINE
PHILADELPHIA HEART INSTITUTE
of Presbyterian Medical Center
I Cardiology
Update
designed for the physician and provides an intensive
survey of the current status of clinical cardiology. . .
Wednesday, April 4, 1990
What’s New in the Diagnosis and Management
of Hypertrophic Cardiomyopathy?
Moderator
Bernard L. Segal, M.D.
3:00-3:30 Hypertrophic cardiomyopathy: differential diagnosis Bernard L. Segal, M.D.
3:30-4:00 The treatment of hypertrophic cardiomyopathy Steven J. Nierenberg, M.D.
4:00-5:00 Case presentations — Unusual forms of hypertrophic
cardiomyopathy T. John Mercuro, M.D.
Panel discussion
Terry Langer, M.D., J. David Ogilby, M.D.,
Henry S. Sawin, M.D , Gary J. Vigilante, M.D
■ Case Presentations and Panel Discussions
■ CME Credits*
■ No Registration Fee
■ Call for Reservation 215-662-8627
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
The Philadelphia Heart Institute at Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
" The University of Pennsylvania School of Medicine is accredited by the Accreditation Council for Continuing Medical
Education to sponsor continuing medical education for physicians. The University of Pennsylvania School of Medicine
designates this Continuing Medical Education activity for 2 credit hours per session in Category 1 of the Physician's
Recognition Award of the American Medical Association."
VOL. 87— NUMBER 3 MARCH 1990
239
(Burlington County Medical
Society)
12 Update on Geriatric Medicine
26 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
17 Unresolved Problems in Acute
Renal Failure
6:30-9:30 P.M.— Overlook
Hospital, Summit
(AMNJ)
18 Fluid and Electrolyte Disorders
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
18 Amputee Rehabilitation and
Prevention
2-3 P.M. — John E. Runnells
Hospital of Union County,
Berkeley Heights
(AMNJ)
19 Nephropathy
2-3 P.M.— Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
19 Nicholas G. Demy Memorial
Lecture
5-6 P.M. — Somerset Medical
Center, Somerville
(Somerset Medical Center)
19 Diabetic Nephropathy
2-3 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
20 Prevention of Lower Extremity
Amputations
8:30-9:30 A. M. — Chilton Memorial
Hospital, Pompton Plains
(AMNJ and NJDOH)
21 MIIENJ Seminar
All Day — MSNJ headquarters,
Lawrenceville
(MIIENJ)
24 Impaired Professional
7:30-8:30 A.M. — Mercer Medical
Center, Trenton
(Mercer Medical Center)
25 Prevention of Lower Extremity
Amputations
1:30-2:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(AMNJ and NJDOH)
26- Clinical Prevention of Lyme
27 Disease
All Day — Robert Wood Johnson
Medical School, Piscataway
(NJ Public Health Association
and UMDNJ)
27 Diabetes in Pregnancy
8:30-9:30 A.M. — Chilton Memorial
Hospital, Pompton Plains
(AMNJ and NJDOH)
27 Developmental Disabilities
Journal Club for Physicians and
Dentists
11:30 A.M. -12:30 P.M.—
Hunterdon Developmental
Center, Clinton
(Hunterdon Developmental
Center)
NEW JERSEY MEDICINE
presents
Continuing
Medical Education
The 14 contributing authors of this special issue, published in 1989,
discuss the present condition of continuing medical education and the future
goals of CME in New Jersey.
Single copy: $5
Ten copies or more: $4
Send check to: NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
■
-
240
NEW JERSEY MEDICINE
Elizabeth General Medical Center Foundation
and
Ross Laboratories
present
The First Annual
IRVING R. FOX MEMORIAL LECTURE
ON PEDIATRIC AMBULATORY CARE
Guest Speaker
BENJAMIN M. SPOCK, M.D.
“Raising Children: Now and Then’’
SUNDAY, APRIL 29, 1990
10:30 A.M.
Elizabeth General Medical Center
Education/Conference Center
925 East Jersey Street
Elizabeth, New Jersey 07201
A buffet brunch will be served prior to the presentation.
No admission charge. Limited seating is available ONLY
by calling 201-558-8479
Acupuncture & Electro-Therapeutics
in Clinical Practice
New York State Boards of Medicine & Dentistry
25 -hour accredited seminar & workshop on latest theories
and techniques of manual & electro-acupuncture, TENS &
simple non-invasive diagnostic methods (including
cardio-vascular, neuromuscular, central nervous systems &
"Bi-Digital O-Ring Test"), applicable towards 300-hour
requirement for certification to practice acupuncture, will be
given periodically for licensed clinicians (with or without
prior training) on 3-day weekends (Fri-Sun) of March
23-25, May 11-13, June 15-17, July 13-15, Sept. 21-23,
and Dec. 14-16, 1990, at Milford Plaza Hotel, 45th St. &
8th Ave., or 110 Fulton St. (12th fl.), New York City.
The 6th Annual International Symposium on
Acupuncture & Electro-Therapeutics will be held at
Columbia University, School of International Affairs, 420
W. 118th St., N.Y. City, during October 25-28, 1990.
These meetings are co-sponsored by the International
College of Acupuncture & Electro-Therapeutics & its official
journal. Acupuncture & Electro-Therapeutics Research. The
International Journal (published by Pergamon Press &
indexed in 15 major indexing periodicals, including Index
Medicus), Heart Disease Res. Foundn, N Y Pain Center of
Long Island College Hospital (a teaching hospital of
SUNY-Health Science Center at Brooklyn); Electrical
Engineering Dept., Manhattan College; Nordic Medical
Acupuncture Society (Scandinavia); Schmerz Therapeutische
Kolloquium (West Germany); Japan Bi-Digital O-Ring Test
Assn; etc. The meetings are also eligible for AMA CME Cat.
I credit (about 40 credit-hours for the Symposium).
For information on meetings or submission or
presentation of papers, contact Symposium Chairman Y.
Omura, M.D., Sc.D., 800 Riverside Drive (8-1) New York,
NY 10032 Tel: (212) 781-6262 (10am to 10pm 7 days a
week) or (212) 928-0658, Dr. Shinnick (212) 727-9674, or
Bro. Michael Losco (212) 920-0162.
Pointing the
way to more
CME credit.
More CME credits for
less money ($10.00).
Practical questions
covering the most im-
portant points from
each article— not just
one symposium article.
Now, more than ever,
you’ll want to read
every issue of
Postgraduate Medicine
from cover to cover!
Earn more CME credit
with Postgraduate
Medicine’s new and
improved CME Program
sponsored by the
Interstate Postgraduate
Medical Association.
4530 W 77th Street
Minneapolis, MN 55435
(612)835-3222
VOL. 87— NUMBER 3 MARCH 1990
241
May
1 Aspiration Syndrome in the
Mentally Retarded
1-2 P.M. — Woodbridge
Developmental Center
(AMNJ)
1 Fourth Annual Internal
8 Medicine Update and
15 Board Review
22 5:30-7:30 P.M. — Cooper Hospital,
29 Camden
( Cooper Hospital/UMDNJ)
2 Medical Lecture Series
9 10:30-11:30 A. M— Christ
16 Hospital, Jersey City
23 ( Christ Hospital)
30
2 Internal Medicine Review
9 Course
16 4-7 P.M. —University Hospital,
23 New Brunswick
(AMNJ and UMDNJ)
3 Computers in Medicine
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
3 Liver Transplantation
11 A.M. — St. Joseph’s Hospital
and Medical Center, Paterson
(St. Joseph ’s Hospital and
Medical Center)
4- Combined Annual Meeting
5 Cherry Hill Inn, Cherry Hill
(New Jersey Society of
Pathologists and PA Association
of Clinical Pathologists)
4 Continuing Medical
11 Education Program
18 12 Noon-1 P.M. — South Jersey
25 Hospital System, Bridgeton
(South Jersey Hospital System)
8 Renal Biopsy Conferences
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
9 Medical Malpractice: Criminal
Law and Tort Issues
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
10 Diabetes-Related
Kidney Disease
1:30-2:30 P.M.- — Vineland
Developmental Center, Vineland
(AMNJ and NJDOH)
10 Update on Geriatric Medicine
24 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
1 1 New Laboratory Diagnostic
Tests
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
14 Retinopathy
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
15 Volume Homeostatis in
Pregnancy
6:30-9:30 P.M. — Overlook
Hospital, Overlook
(AMNJ)
16 Nutritional Assessment
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
16 Dilemmas of Dying
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
17 Continuing Medical Education
12 Noon — Somerset Medical
Center, Somerville
(Somerset Medical Center)
18 Retinopathy
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
18 Rheumatoid Arthritis: Etiology
and Pathogenesis
12:15-1:15 P.M. — Kennedy
Memorial Hospital, Stratford
(UMDNJ and Kennedy Memorial
Hospital)
19 Morbidity and Mortality
26 Conference
8:30-10 A.M. — New Jersey
Medical School, Newark
(UMDNJ)
23 Functional Assessment
of the Elderly
10:30-11:30 A.M. — Christ
Hospital, Jersey City
(AMNJ)
24 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
( Saint Barnabas Medical Center)
ONCOLOGY
April
1 1 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
13 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
26 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
26 Dinner Meeting
6:30-9:30 P.M. — The Hyatt,
New Brunswick
(AMNJ — Head and Neck
Oncology Section)
May
9 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
1 1 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
16 First Annual Joint Meeting
6:30-9:30 A.M. — The Manor,
West Orange
(Head and Neck Oncology and
Radiation Oncology Sections —
AMNJ)
24 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
ORTHOPEDICS
April
17- Annual Spring Meeting
22 Royal Antiqua Hotel, Antiqua
(New Jersey Orthopaedic Society)
PEDIATRICS
April
5 Pediatric Grand Rounds
12 8:30-9:30 A.M. — Robert Wood
19 Johnson Medical School, MEB,
26 102, New Brunswick
(UMDNJ)
11 Learning Disabilities
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
18 Neonatal Resuscitation and
Stabilization
7:30 A.M. -5:15 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
19 Update in Aspects of Pediatrics
Marriott Hotel, Saddle Brook
(Northern NJ Pediatric Society)
19 Pediatric Seizures
6:30-7:30 P.M. — Marriott Hotel,
Saddle Brook
(Northern New Jersey Pediatric
Society)
May
3 Pediatric Grand Rounds
10 8:30-9:30 A.M. — Robert Wood
17 Johnson Medical School, MEB,
24 102, New Brunswick
(UMDNJ)
4 Sudden Infant Death
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
...
242
NEW JERSEY MEDICINE
JUNE 16
10th ANNUAL ADVANCES
IN GASTROENTEROLOGY
BALLY'S PARK PLACE
ATLANTIC CITY, NEW IERSEY
For further
information, contact:
Registration Manager
SLACK Incorporated
6900 Grove Road
Thorofare, N.J. 08086
609-848-1000
— ELEVENTH ANNUAL ” '
COMPREHENSIVE COURSE
IN OCCUPATIONAL MEDICINE
UNIVERSITY OF MEDICINE AND
DENTISTRY OF NEW JERSEY
DEPT OF ENVIRONMENTAL AND COMMUNITY MEDICINE
ROBERT WOOD JOHNSON MEDICAL SCHOOL
PISCATAWAY, NEW JERSEY
DATE:
June 4-22, 1990/15 weekdays/8: 30 a. m, -4:30 p.m.,
6 evening classes/6:30-8:30 p.m,
PURPOSE:
To provide a comprehensive review of key issues and concepts in
Occupational Medicine given by eminent specialists from univer-
sity, government and industry. To aid in obtaining board eligibili-
ty and certification.
ACCREDITATION:
The University of Medicine and Dentistry ol New Jersey-Center
lor Continuing Education certilies that this continuing medical
education activity meets the criteria for 90 hours of credit in
Category 1 for the Physician's Recognition Award of the American
Medical Association, provided the program is completed as
designed.
SUBJECTS:
Industrial Hygiene, Occupational Disease, Toxicology, Practice
of Occupational Medicine, Epidemiology and Biostatistics,
Ergonomics, Public Health Administration.
INQUIRIES: Sophie Martin (201)463-4707
UMDNJ-Center for Continuing Education
675 Hoes Lane, Piscataway, NJ 08854-5635
VACATION SEMINARS
— Fully Accredited —
Medical Malpractice
"Damage Control” and
AIDS: An Overview
(Satisfies Relicensure Requirements)
2-5 Day Programs
Offered WEEKLY At:
4 CLUB MED VILLAGES
(Dom. Rep., FL, Mex., Nassau)
DISNEY WORLD*, CRESTED BUTTE (CO)
LAKE PLACID, LAKE TAHOE
MIAMI BEACH, N. CONWAY (NH)
PHOENIX, POCONO MTS. (PA)
SAN DIEGO, STEAMBOAT SPRINGS (CO),
& a DUDE RANCH (AR)
*3 & 4 day Bahamas Cruises
offered (special rate)
Registration fee: $125-225
(8-20 hours CME)
Spouse Free
Presented by:
CURRENT CONCEPT SEMINARS
America’s Largest Independent
Producer of CME Programs
5700 Stirling Road, Hollywood, FL 33021
(305) 966-1009 • (800) 969-1009
Advanced Management
Program eor Clinicians
at NYU
AMPC is a Master’s Degree program for clinicians
who want to build the skills that will allow them
to act upon (rather than just react to) changes in
the health care sector. AMPC:
• Leads to an MS degree in health policy and
management.
• Provides training in financial analysis,
quality assurance, information systems,
marketing, management, policy and more.
• Offers courses in the evenings and on Sat-
urdays to accommodate clinicians’ busy
schedules.
For more information about AMPC, call
(212) 998-7460
Mrs. Cindy Mazur
738 Tisch Hall
40 West 4th St.
New York, NY 10003
VOL. 87— NUMBER 3 MARCH 1990
243
PSYCHIATRY
April
3 Divorce
8:30-10 A.M. — Department of
Psychiatry, Elizabeth General
Hospital, Elizabeth
(Elizabeth General Hospital)
5 Case Seminars To Improve
19 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
5 Alzheimer’s Disease
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation)
10 Grand Rounds
17 8:30-10 A.M. — Department of
Psychiatry, Elizabeth General
Hospital, Elizabeth
(Elizabeth General Hospital)
12 Genetics for the Clinical
Psychiatrist
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation)
18 Psychiatry and the Law
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
19 Psychiatric Illness: It’s in the
Family
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation )
24 Couples Therapy
8:30-10 A.M. — Elizabeth General
Hospital, Elizabeth
(Elizabeth General Hospital)
25 Nutrition Effects
All Day — Carrier Foundation
( Carrier Foundation)
25 Grand Rounds
2:30-4 P.M. — Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital)
May
1 Psychiatry Grand Rounds
8 8:30-10 A.M. — Elizabeth General
15 Medical Center, Elizabeth
22 (Elizabeth General Medical
29 Center)
3 Case Seminars To Improve
17 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
3 PICA Syndrome and Psychiatry
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation)
10 The Use of Video in Psychiatric
Treatment
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
23 High Anxiety
All day — Carrier Foundation,
Belle Mead
( Carrier Foundation)
24 Narcolepsy
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
31 The Borderline Personality in
the Hospital Setting
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
RADIOLOGY
April
19 1989-1990 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of New
Jersey-Diagnostic Section,
AMNJ)
26 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
May
14 Ultrasound
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
17 1989-1990 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of
New Jersey-Diagnostic Section,
AMNJ)
24 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
SURGERY AND ITS SPECIALTIES
April
1 Surgical Treatment of
Cardiothoracic Disease
10-11 A.M. — New Jersey Medical
School, MSB, 506B, Newark
(UMDNJ)
3 Weekly Vascular Case
10 Conference
17 7:30-8:30 A.M. — Robert Wood
24 Johnson Medical School, MEB,
108B, New Brunswick
(UMDNJ)
7 Surgical Treatment of
Cardiothoracic Disease
10-11:30 A.M. — New Jersey
Medical School, 506B, Newark
(UMDNJ)
21 Morbidity and Mortality
28 Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B.
Newark
(UMDNJ)
23 Plastic and Reconstructive
Surgery
12 Noon-1 P.M. — Hospital Center
at Orange
(AMNJ)
24 Englewood Surgical Society
Lecture Series
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society)
25 Journal Club, Section of
Cardiothoracic Surgery
6:30-9:30 P.M. — 2 Mountain Ridge
Drive, Livingston
(UMDNJ)
May
1 Weekly Vascular Case
8 Conference
15 7:30-8:30 A.M. — Robert Wood
22 Johnson Medical School, MEB,
29 108B, New Brunswick
(UMDNJ)
6 Surgical Treatment of
Cardiothoracic Disease
10-11 A.M. — New Jersey Medical
School, MSB, 506B, Newark
(UMDNJ)
10- Fourth Annual Meeting
13 Sheraton Boston Hotel and
Towers, Boston
(Eastern Vascular Society)
26 Englewood Surgical Society
Lecture Series
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society)
26 Morbidity and Mortality
Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
UROLOGY
April
6 Urology Grand Rounds
13 New Jersey Medical School,
20 MSB, C600, Newark
27 (UMDNJ)
18 Annual William P. Burpeau
Award Dinner and Lecture
6 P.M. — The Manor, West Orange
(AMNJ)
4 Urology' Grand Rounds
1 1 New Jersey Medical School,
18 MSB, C600, Newark
25 (UMDNJ)
May
244
NEW JERSEY MEDICINE
IN MEMOHIAM
Anthony J. Balsamo. At the
age of 79, Anthony John Balsamo,
MD, died on November 29, 1989.
Born in New York City, Dr.
Balsamo was awarded his medical
degree from Hahnemann Medical
School, Pennsylvania, in 1938; the
following year, he received his
license to practice in New Jersey.
A urologist, Dr. Balsamo was the
director of the Department of
Urology at Bayonne Hospital, and
served as a consultant in his
specialty at St. Mary’s Hospital,
Hoboken. In addition, he was an
adjunct professor of urology at the
New York Polyclinic Medical
School and Hospital. A member of
our Hudson County component
and of the American Medical As-
sociation, Dr. Balsamo was a fel-
low of the American College of Sur-
geons and of the American Uro-
logical Association.
Jules E. Baime. At the age of
79, Jules Edgar Baime, MD, died
on December 12, 1989. A retired
pediatrician for the past five years,
Dr. Baime was a member of our
Essex County component and of
the American Medical Association.
Born in Newark in 1910, Dr. Baime
earned his medical degree from the
Ecclesiastical Medical School,
Ohio, in 1936. Dr. Baime was the
founder of the outpatient pediatric
clinic at Newark Beth Israel Medi-
cal Center and also served as medi-
cal director for the Daughters of
Israel Geriatric Center, West Or-
ange, from 1978 to 1985. During his
career, Dr. Baime was affiliated
with East Orange General Hospi-
tal, The Hospital Center at Or-
ange, Newark Beth Israel Medical
Center, and Saint Barnabas Medi-
cal Center, Livingston. During
World War II, Dr. Baime served in
the U.S. Air Force from 1942 to
1946.
Sigmund J. dayman. We have
been notified of the death of
Sigmund Jonas dayman, MD, a
member of our Middlesex County
component. Born in 1908 in New
York City, Dr. dayman was
awarded his medical degree in 1936
from the University of Zurich
Medical School, Switzerland. A
dermatologist, Dr. dayman was a
diplomate of the American Board
of Dermatology and a fellow of the
American College of Dermatology.
During his career, Dr. dayman
was associated with Perth Amboy
General Hospital, and Bellevue
Medical Center, New York. He
served as a major in the LTnited
States Army from 1941 to 1947.
Jules Cooper. Word has been
received of the death of Jules
Cooper, MD, a retired member of
our Cape May County component.
Born in 1905, Dr. Cooper received
his medical degree from the Uni-
versity of Maryland School of
Medicine in 1934. Upon comple-
tion of his residency in Colorado,
Dr. Cooper relocated to Woodbine
where he practiced as a general
physician for more than 50 years.
During his lengthy career, Dr.
Cooper was former medical direc-
tor of Woodbine Developmental
School and was affiliated with
Shore Memorial Hospital, Somers
Point, and Burdette Tomlin Me-
morial Hospital, Cape May Court
House. Dr. Cooper also will be re-
membered as a founder and instru-
mental force behind the Woodbine
Ambulance Corps and purchaser of
its first ambulance. In 1984, Dr.
Cooper was recognized by MSNJ
and was awarded the Golden Merit
Award for his years of service to the
medical community. Dr. Cooper
served as an officer in his county
society, and was a member of the
American Medical Association and
of the Toastmasters Club of Atlan-
tic City. He served as a captain in
the United States Army from 1942
to 1943.
James Monaghan. A member
of our Essex County component,
James Matthew Monaghan, MD,
died on November 29, 1989. Born
in 1926, Dr. Monaghan earned his
medical degree from Jefferson
Medical College, Pennsylvania, in
1950. He completed an internship
at Jefferson Hospital, and served a
fellowship in radiology at Colum-
bia Presbyterian Hospital, New
York City. At the time of his death,
Dr. Monaghan was a retired radi-
ologist, past-president of the medi-
cal and dental staff, and past
trustee of the Hospital Center
at Orange. In addition, Dr.
Monaghan was past chairman of
the Radiologic Technology Board
of Examiners, and past-president
of the Radiologic Society of New
Jersey. Dr. Monaghan was a
diplomate of the American Board
of Radiology and a fellow of the
American College of Radiology.
During World War II and the
Korean conflict, Dr. Monaghan
served in the Army.
Arthur G. Murphy. Word has
been received of the death on April
8, 1989 of a retired member of our
Essex County Medical Society.
VOL. 87— NUMBER 3 MARCH 1990
245
Born in 1914 in Brooklyn, New
York, Arthur Gordon Murphy,
MD, received his medical degree
from Cornell Medical School, New
York, in 1940. After serving in the
United States Medical Corps from
1941 to 1945, Dr. Murphy was
awarded his license to practice in
New Jersey. An obstetrician-
gynecologist, Dr. Murphy was af-
filiated with The Mountainside
Hospital, Montclair, during his
lengthy career. A member of the
American Medical Association,
Dr. Murphy was a fellow of the
American College of Obstetricians
and Gynecologists.
Sushila B. Patel. A member of
our Middlesex County component,
Sushila B. Patel, MD, died on De-
cember 6, 1989. Born in 1934 in
India, Dr. Patel earned her medi-
cal degree at Baroda Medical
School, India, in 1963. After
serving an internship at Orange
Memorial Hospital and a fellow-
ship at Middlesex General Hospi-
tal, New Brunswick, Dr. Patel re-
ceived her license to practice in
New Jersey in 1973. An obstetri-
cian-gynecologist, Dr. Patel was
affiliated with J.F. Kennedy Medi-
cal Center, Edison, and Rahway
Hospital. Dr. Patel was a member
of the American Medical Associa-
tion and a diplomate of the Ameri-
can Board of Obstetrics and
Gynecology.
Daniel W. Popenoe. At the un-
timely age of 39, Daniel Ward
Popenoe, MD, died on December
14, 1989. Born in California, in
1950, Dr. Popenoe earned his
medical degree at the University of
Southern California, Los Angeles,
in 1980. He served a residency at
SUNY-Downstate, New York, and
a fellowship in hematology/on-
cology at Columbia University,
New York. He received his New
Jersey medical license in 1986. Af-
filiated with The Valley Hospital,
Ridgewood, Dr. Popenoe was a
member of our Bergen County
component and of the American
Society of Clinical Oncology. Dr.
Popenoe retired from his Ho-Ho-
Kus practice in internal medicine,
oncology, and hematology shortly
before his death.
Walter Stewart. At the age of
90, Walter Stewart, MD, a mem-
ber of our Atlantic County compo-
nent, died on November 28, 1989.
Born in Atlantic City, Dr. Stewart
received his medical degree from
Johns Hopkins University Medical
School, Maryland, in 1923. Award-
ed his license to practice in New
Jersey in 1925, Dr. Stewart was a
pediatrician in his hometown from
1926 to 1983, serving as chief of
pediatrics at Atlantic City Medical
Center from 1927 to 1959. In 1932,
Dr. Stewart was the recipient of
the Citizen of the Year Award for
his service during a polio epidemic.
In 1976, Dr. Stewart was honored
with the Medical Society of New
Jersey’s Golden Merit Award for 50
years of service to his community.
Dr. Stewart served as medical di-
rector of Florence Crittenton Home
in Atlantic City, medical director
at Children’s Seashore House, and
physician for the Friends School.
Dr. Stewart was a charter member
of the American Academy of
Pediatricians, and was a member
of the AMA.
Edward H. Weiser. Family
practitioner Edward Harry Weiser,
MD, a member of our Sussex
County component, died on De-
cember 1, 1989, after a short ill-
ness. Born in Brooklyn, New York,
in 1907, Dr. Weiser was awarded
his medical degree from the Colo-
rado Medical School in 1938; five
years later, he received his license
to practice in New Jersey. For the
next 50 years, Dr. Weiser served as
a physician in Sussex Borough at
the Wallkill Valley Hospital, and
as physician to the Borough Police
Department, the High Point Re-
gional High School, and the
Sussex-Wantage Regional Schools.
In addition, he was Sussex County
coroner. Dr. Weiser was a United
States World War II Army veteran,
a past-president of the New Jersey
Association of Family Practicing
Physicians, a member of the
American Medical Association,
and a former chief of staff at the
former Alexander Linn and Frank-
lin Hospital.
David C. Wilson. An emeritus
member of our Morris County
component, David Cole Wilson,
Jr, MD, died on October 7, 1989.
Born in 1924 in Clifton Springs,
New York, Dr. Wilson earned his
medical degree at the University of
Virginia Medical School in 1947.
He served as a captain in the Unit-
ed States Army until 1952; he re-
ceived his New Jersey license in
October 1952 and was affiliated
with Morristown Memorial Hospi-
tal. A psychiatrist, Dr. Wilson lim-
ited his practice to psychotherapy.
Dr. Wilson was a member of the
AMA and of the American Psy-
chiatric Association.
IN MEMORIAM
Please send all information for member
obituaries to the following address:
Membership Department
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
246
NEW JERSEY MEDICINE
■' g
m
EDITORIAL CRITERIA
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
vision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statement accompany-
ing material offered to NEW JER-
SEY MEDICINE must contain the
following language and must be
signed by all authors.
“In consideration of NEW JER-
SEY MEDICINE taking action in
reviewing and editing my sub-
mission, the author(s) undersigned
hereby transfers, assigns, or other-
wise conveys all copyright own-
ership to the Medical Society of
New Jersey, in the event that such
work is published in NEW JER-
SEY MEDICINE.
Specifications. Submit two
manuscripts that must be type-
written and double-spaced on SV-i"
by 11" paper. Statistical methods
should be identified.
Authors are asked to seek clar-
ity, accuracy, and originality; at-
tention to details of grammar,
spelling, and typing are important.
The title page should include the
full name, degrees, and affiliations
of all authors, and the name and
address of the author to whom re-
print requests and correspondence
should be sent.
The author should submit a 30-
word abstract.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission must be
submitted.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote
with the first use of the generic
name. Proprietary names of de-
vices should be indicated by the
registration symbol — ".
References should not exceed 35
citations except in review articles,
and should be cited consecutively
by numbers in parentheses at the
end of the sentence. The reference
list should be typewritten and
double-spaced on separate 8 Vi" by
11" sheets in numerical order. The
style of NEW JERSEY MEDI-
CINE for references is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
viewers and the authors will be
permitted, but authors will be in-
formed of the reviewers’ com-
ments. Galley proofs will be sub-
mitted to the author for correction.
Reprint Orders. Reprints may be
ordered after the author is notified
that the article has been selected
for a specific issue. A check for the
cost of reprints must accompany
that order.
Communications. All com-
munications should be sent to the
editor, NEW JERSEY MEDI-
CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
VOL. 87— NUMBER 3 MARCH 1990
247
General Practice
Clinic Opportunity
Ft. Dix, New Jersey
Full-time and part-time opportunities available at north-
ern New Jersey U.S. Army health care clinic. No call
responsibility. Approximately 25-30 patients are seen
each day. You are offered a competitive rate of reim-
bursement, occurrence malpractice insurance, CME al-
lowance and assistance with relocation expenses.
Contact:
Terry Connolly
Spectrum Emergency Care, Inc.
P.O. Box 27352
St. Louis, MO 63141
1-800-325-3982 ext. 5334
OB/GYN Generalist. Interested in GYN ULTRA-
SOUND? Excellent opportunity to build national
reputation working in OB/GYN Department of
large, teaching hospital in the Northeast. Assist
renowned OB/GYN; 6,000 ultrasound studies per
year; state of the art equipment; work with resi-
dents on daily basis; teach; maintain private prac-
tice. Salary and benefits. Confidentiality respect-
ed. For more information about this opportunity
and others call:
Marion Novack, Senior Associate, E. G. Todd
Associates, 535 5th Ave., New York, NY 10017
(212) 599-6200 collect or (800) 221-4762
PRIMARY
CARE
PHYSICIAN
Full-time position available for Board
Certified/Eligible Physician to staff Pri-
mary Care walk-in practice.
Practice located in Monmouth County,
Central New Jersey, located by beauti-
ful New Jersey Shore. One hour from
NYC and Philadelphia.
“New Jersey and You, Perfect Together’’
Phone or send curriculum vitae to: J. Covert,
BAYSHORE COMMUNITY
HEALTH SERVICES, INC.
727 No. Beers Street, Holmdel, NJ 07733
(201) 739-5986 FAX: (201) 739-5887
The Air Force Reserve offers you a rewarding second career in
the medical field, even if you have no previous medical ex-
perience. You can learn new skills or sharpen old ones. You’ll
need to commit just one weekend a month plus two weeks each
year to this rewarding opportunity.
With or without prior military experience, you may qualify to
become a member of the Air Force Reserve Medical Team on the
ground or in the sky. Call today.
Call: (609) 724-4303 To: USAF Reserve RCRTG
Or Fill Out Coupon and Mail Today I 514 MAW/RS
McGuire AFB, NJ 08641-7004
Name
Address
City State Zip
Phone.
Date ot Birth.
Prior Service?.
.Yes .
.No
AIR FORCE RESERVE
14-007-0007 A GREAT WAy T0 SERVE
£>
INDUSTRIAL
PHYSICIAN
Would you like to live in the Rocky Mountains in an area that
is unsurpassed in outdoor recreational opportunities? EG&G
Idaho is the prime operating contractor for the U.S. Depart-
ment of Energy at the Idaho National Engineering Laboratory.
We are located in the vicinity of Sun Valley, Jackson Hole and
the Yellowstone & Teton National Parks.
POSITION: MD or DO with a strong background in general,
internal, or emergency medicine. Responsibilities will include
physical examinations and medical certifications, emergency
treatment of occupational and non-occupational injuries, fit-
ness for duty evaluations and health counseling. Opportunity
for career development in occupational and preventive medi-
cine.
QUALIFICATIONS: Board Certification or Board Eligibility in
Occupational Medicine, Family Practice, Internal Medicine, or
Emergency Medicine is desirable. Must have current license
and be eligible to become licensed in the State of Idaho.
COMPENSATION: Forty hour week with generous benefits
and compensation package.
If interested and qualified, please send C.V. and salary re-
quirements to: Employment Services, (PSW-21), EG&G
Idaho, Inc., P.O. Box 1625, Idaho Falls, Idaho 83415. We
are an equal opportunity employer. M/F/H/V. Minority candi-
dates are encouraged to apply. U.S. citizenship required.
<5^ Idaho, Inc.
248
NEW JERSEY MEDICINE
BOARD AUTHORIZES SUIT TO CHALLENGE
NO-FAULT BAN ON BALANCE BILLING AND NEW LICENSURE TAX
The Florio Administration, maintaining dominant procedural and
substantive control of the New Jersey Legislature, enacted a
revision of the no-fault law for automobile insurance.
The new law provides for a medical fee schedule that would pay
completely 75 percent of the doctors in the state; places a ban
on billing in excess of the schedule; and taxes each physician
$100 per year to help offset the $3 billion deficit of the
Automobile Joint Underwriters Association.
MSNJ efforts to oppose the ban on balance billing and the
license tax were thwarted by the Governor's control of the
political process.
At its meeting on March 18, 1990, the MSNJ Board of Trustees
authorized the firm of Kern Augustine Conroy & Isele to file a
suit on behalf of the membership, attacking the constitution-
ality of the ban on balance billing and the license fee tax.
MALPRACTICE SURCHARGE
The MSNJ request for a stay on the malpractice surcharge
collection was denied by both the Insurance Department and the
Appellate Division. It has been appealed to the State Supreme
Court but a ruling has not been rendered. The primary
litigation remains in the Appellate Division and is being
scheduled for hearing in early June 1990. Herbert Stern,
representing MSNJ and its members, has requested the Court to
schedule the case at an earlier date if possible.
MSNJ
NEWSLETTER
INAUGURAL RECEPTION The Union County Medical Society and the Medical Society of New
Jersey invite you to celebrate the inauguration of Douglas M. Costabile,
MD, as president of the Medical Society of New Jersey, at a gala
inaugural reception and dinner dance. This social event will be held on
Tuesday, May 8, 1990, at the Sands Hotel, Casino & Country Club,
Atlantic City. The reception will begin at 6:30 P.M. in the International
Ballroom; tickets will be $10 per person. The dinner dance will start at
7:30 P.M. in the Copa Room; tickets will be $50 per person. To reserve
tickets, contact the Union County Medical Society.
AMA- The American Medical Association Hospital Medical Staff Section
HMSS (HMSS) will hold its 15th Assembly Meeting from June 21 to 25, 1990,
at the Chicago Marriott Hotel. Highlights from the meeting will include
an educational program entitled, “Building Effective Hospital Physician
Relationships: Ten Success Stories”; presentation by the AMA-HMSS
Governing Council of reports on medical staff issues including the impact
of hospital bankruptcy, the role of hospital governing boards in pro-
fessional review, and information sharing among medical staff; rec-
ommendation of policy to the House of Delegates; and elections for
positions of chairman, vice-chairman, secretary, and a member-at-large.
For information about the New Jersey Hospital Medical Staff Section,
please call Diana Gore, at MSNJ headquarters, 609/896-1766.
LEGAL Each month there are a number of frantic calls from physicians who have
NOTES received notification from the PRO that they have been assessed
“points” for mismanagement of patients. The first questions asked are:
What do these points mean? What can you do about them?
Points are assessed by the PRO based upon its determination that a
physician has mismanaged the care of a patient. The greater the effect
of the mismanagement, the greater the number of points. For example,
“mismanagement without the potential for adverse effects on the pa-
tient” results in the imposition of 1 point. Five points are imposed for
“mismanagement with the potential for significant adverse effects on the
patient” and 25 points are imposed for “mismanagement with significant
adverse effects on the patient.”
Thus, the number of points has nothing to do with the degree of mis-
management, but is determined solely upon the actual harm, if any, to
the patient.
Associated with this point system are sanctions. Accumulate 5 points
and you will receive notification that a problem exists. Obtain 10 points
and you will be required to complete continuing education. Fifteen
points will result in intensified review, which is a potentially serious
sanction since someone will be looking over your shoulder for perhaps
three to six months watching every test you order and every word you
write in a chart. The accumulation of 20 points can result in prepayment
or preadmission or preprocedure reviews, or referral to a hospital com-
mittee for action. Finally, receipt of 25 points — obtainable by one single
VOL. 87— NUMBER 4 APRIL 1990
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MSNJ NEWSLETTER
management failure that adversely affects a patient — may result in a
recommendation by the PRO Sanctions Committee to revoke your privi-
leges to treat Medicare patients and referral to the State Board of
Medical Examiners for action on your medical license.
Unfortunately, the PRO takes the position that the fact that points are
assessed does not entitle you to a hearing or any other type of due
process. Rather, the PRO insists it is using the point system solely for
“internal tracking.” Thus, unless they also decide to initiate sanctions,
such as suspension from the Medicare program, they tell us the doctor
has no right to challenge the assessment of points.
Since the assessment of points is not subject to challenge, it is imperative
that the physician’s initial response to a PRO inquiry be full, complete,
accurate, and understandable. This may be the only opportunity the
physician has to maintain a clean record. Before responding, the hospital
chart must be reviewed carefully. If any question exists concerning the
appropriateness of care, have a colleague offer suggestions. Then,
prepare an initial draft response. The response should specifically ad-
dress the item or items targeted by the PRO. Ordinarily, it should not
contain a full-blown description of the entire case. Before submitting the
response, contact your health care attorney for review. If you are a
member of the Medical Society of New Jersey Endorsed PRO Defense
Program, contact Kern Augustine Conroy & Isele. You already have paid
for this legal advice — take advantage of it. There will be no additional
cost to you for this service.
Depending upon the questions asked, it may be appropriate to also
supply statements by consultants, family members, hospital personnel,
or experts in the field. On occasion, use of authoritative journal articles,
textbooks, or treatises should be included.
You will have no further opportunity, ordinarily, to state your case unless
the PRO seeks to impose sanctions. At that point, the burden falls upon
you to prove to the PRO that its decision was wrong. It is much easier
to provide full information at this stage than to try to convince the PRO
it was wrong at a later time.
Any correspondence received from the PRO must be viewed as a poten-
tially serious event. Your response should be clear, concise, factual, and
medically and legally correct, and should address each of the concerns
raised by the PRO. Where appropriate, include backup materials sup-
porting your position. □ Kern Augustine Conroy & Isele, P.A.
NAMES The New Jersey NAMES Project AIDS Memorial Quilt will be on dis-
PROJECT Play at Rutgers’ Louis Brown Athletic Center, Piscataway, on April 21
to 23; Rutgers’ Gold Dome, Newark, on May 18 to 20; Brookdale Com-
munity College, Lincroft, on June 1 to 3; and Convention Hall Ballroom,
Atlantic City, on June 8 to 10. The Quilt, which began as a memorial,
has become one of the nation’s most valuable tools for promoting a
compassionate and educational dialogue about AIDS. The Quilt provides
a clear message: human beings die of AIDS.
Just when you’ve had it up to your ears with acronyms dealing with the
regulation of medicine, you rediscover the excitement of the practice of
medicine. Part of that excitement is the astonishing rate of change of
the medical knowledge base. The corollary to this information explosion
is the challenge to manage it competently with respect to new thera-
peutic and diagnostic aids in the care of patients. Ours is a profession
of lifelong learners; this contributes to our drive and vitality and to
FUN/FRUSTRATION
RATIO OF
MEDICAL EDUCATION
262
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
making medicine fun. However, fun is hardly the word that comes to
mind, when after a long day, you eyeball a stack of unopened journals.
In 1989, the physician has a number of tools to increase the “fun/
frustration” ratio in the continuing learning process. The most obvious
is the microcomputer, an affordable and powerful manipulator of infor-
mation. Careful selection of the software and databases now available
can lead to relevant and efficient learning. Collaborations between com-
puter scientists and physicians are producing programs that can assist
in diagnosis and treatment and also educate the user in the reasoning
behind the computer-generated recommendations. Other examples are
continuing medical education programs and access to the databases of
the National Library of Medicine.
Retaining clinically relevant information with any modality is less likely
to stick if the subject is not related to patient care or at least a written
case. Medical educators refer to this as problem-based learning and the
concept is as applicable to practicing physicians as it is to medical
students and residents. The human interaction with patients and the
resolution of real clinical problems are the basis of lessons we remember.
How often can we make that claim, despite the beauty of the conference
site, for continuing medical education lectures?
The discipline of clinical epidemiology has contributed practical and
efficient methods to assist physicians in self-education. Guidelines for
efficiently reading medical journals, criteria for assessing the validity
and applicability of clinical evidence, new ways to look at the clinical
significance of studies, and more rigorous evaluations of diagnostic tests
are some of the important advances in this field. Decision analysis is
another area of clinical epidemiology which has received much attention
recently. Still growing as a discipline to resolve clinical questions in a
practical manner, decision analysis is a powerful tool in clinical educa-
tion. Its strength lies in making the elements of a clinical decision
explicit; forcing the learner to explore all options and consider quality
of evidence.
You do not have to become a computer programmer, a clinical
epidemiologist, or decision analyst to reap the benefits of these educa-
tional tools. Beginning with this issue, these tools will be incorporated
into discussions of interesting cases seen at UMDNJ (page 305). This
problem-based medical education series will familiarize readers with
educational tools used at New Jersey Medical School in an effort to
produce lifelong learners. We sincerely hope it will improve the “fun/
frustration” ratio of your continuing education. □ Howard A. Holtz, MD
HOMELESS The Young Physicians Committee of the Medical Society of New Jersey
AWARENESS and the Young Lawyers Division of the New Jersey State Bar Association
will be presenting the “First Annual Homeless Awareness Conference.”
This program is being held on May 11, 1990, at the New Jersey Law
Center, New Brunswick, from 9 A.M. to 4:45 P.M. The objective of the
program is to heighten public awareness of the homelessness crisis and
to train professionals in the areas of care required by homeless individ-
uals. The cost for the all-day program is $20, and for further information,
contact Ron Rouse at 609/896-1766.
RESTRUCTURING The Federation’s executive board unanimously adopted a resolution that
UNCOMPENSATED charges the uncompensated care system unfairly subsidizes employers
QApg that do not provide health insurance to workers at the expense of em-
ployers that do. AFL-CIO President Charles Marciante stated that under
the current system, anyone who pays a hospital bill through an insurance
VOL. 87— NUMBER 4 APRIL 1990
263
MSNJ NEWSLETTER
premium or out of pocket shares in the cost of uncompensated care and
subsidizes those who cannot afford or refuse to purchase health in-
surance. Uncompensated care is reimbursed to hospitals by means of
a uniform surcharge. The resolution indicated that 11 percent of the
population, or 850,000 people, lack health insurance. And, 41 percent
of the uninsured hold jobs and between 35 to 40 percent are dependents
of workers, according to Marciante. The resolution also indicated that
most new businesses in New Jersey are in service or retail industries,
that traditionally do not provide health insurance coverage. AFL-CIO
leaders called on lawmakers to consider establishing mandated health
insurance or tax programs similar to those enacted in Massachusetts and
Hawaii. Senate President John Lynch (D-Middlesex) has endorsed the
recommendation.
REPORTING AIDS
The Camden County Borough has been found liable in federal court
because employees circulated information that a resident was infected
with the AIDS virus. U.S. District Court Judge Stanley S. Brotman ruled
against a police officer and Runnemede for violating the right of privacy
of the family of a man inflicted with the disease. The situation occurred
when a police officer told a neighbor of a man arrested for unlawful
possession of a needle that the man was HIV-positive. The suit alleged
that as a result of the police officer’s disclosure, the family suffered
harassment, discrimination, and humiliation.
BRAIN DEATH BILL
A bill that would legislatively recognize the concept of “brain death”
is set to go before the full state Senate for a vote. The bill permits a
person to be declared dead if breathing and circulation are maintained
solely by machine and the patient has sustained irreversible cessation
of all functions of the entire brain. The bill also provides an exception
to this definition of death if it violates a patient’s religious beliefs or
moral convictions. In these cases, a person could be declared dead if the
heartbeat and breathing had irreversibly stopped. The acceptance of the
brain death definition is an important factor in the area of organ trans-
plantation. MSNJ is objecting to the religious exemption provision.
NEW JERSEY
AND AIDS
Although the count is not finished, an additional 1,791 AIDS cases were
reported in New Jersey in 1989. The state has been counting cases since
1981 and the total is expected to increase from 6,146 to more than 7,937
when the 1989 count is completed, according to the State Department
of Health. More than 4,900 New Jerseyans have died of AIDS since 1981
and about 30 percent of those diagnosed last year already have died.
NURSING HOME
REIMBURSEMENTS
Nursing home industry leaders argue that New Jersey’s low rate of
reimbursing nursing homes for Medicaid residents violates federal law
and accounts for half of the facilities’ $10 loss per patient day. If the
problem was to be corrected, it could cost $36 million in its first full
budget year. The State Department of Human Services was petitioned
to live up to its federally mandated obligations by two nursing home
groups, representing 32,000 residents in 352 facilities.
HEART TRANSPLANT
CENTER
The state’s only heart-transplant center was unveiled late last month
at Newark Beth Israel Medical Center. In addition to the service, a new
state-of-the-art coronary care unit (CCU) and a new neonatal intensive
care unit (NICU) were opened. According to the Hospital, the new 24-
bed CCU makes it the largest cardiac surgical program in the state.
HCFA PHYSICIAN
HCFA announced the “Performance Standard” target of 9.1 percent for
FEE TARGET physician fee increases in fiscal year 1990. If fees exceed this amount,
the physician fee increases for 1992 might be reduced. Secretary of
264
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
Health and Human Services, Louis Sullivan, MD, believes physicians,
as a result, will determine what services are necessary and those that
are inappropriate or ineffective will be eliminated. Many question
whether that will occur with a system that will not impact the physicians
for some two years down the road.
The M. Louise Carpenter Gloeckner, MD, Summer Research Fellowship
Award Committee of the Archives and Special Collections on Women
in Medicine, The Medical College of Pennsylvania, is accepting appli-
cations for summer 1990 research using materials in the Archives and
Special Collections at the College. The Archives houses the business and
academic records of The Medical College of Pennsylvania dating from
its founding in 1850 as the Female Medical College of Pennsylvania. Two
grants of up to $1,500 each for four to six weeks of research. For an
application and description of the Fellowship, contact the Archives and
Special Collections on Women in Medicine, The College of Penn-
sylvania, 3300 Henry Avenue, Philadelphia, PA 19129.
INSURANCE REFORMS The state Industrial Union Council (IUC) recently indicated limited
support for Governor Jim Florio’s auto insurance reform package. The
section IUC reserved judgment on was a proposal to transfer the cost
and coverage for personal injury protection (PIP) to health insurance
carriers. The labor commissioner urged the leadership of IUC to consider
the control of health care costs as the number one issue that must- be
faced because that is “the number one item out of control in New
Jersey.” According to IUC, “Most strikes now occur over who should
shoulder any rise in medical costs.” Meanwhile, the AFL-CIO an-
nounced “enthusiastic support” for the auto insurance package. This
was after an independent study indicated the move would mean only
a 1 to 2 percent or $20 to $40 annual increase per person in health
insurance costs. Blue Cross/Blue Shield of New Jersey has estimated the
cost to be $100 annually.
KICKBACK CASE The Inspector General’s Office has reached a settlement with
SETTLED SmithKline Beecham Clinical Laboratories regarding referrals by phy-
sicians of Medicare and Medicaid business to three California labora-
tories owned by such physicians and managed by SmithKline.
SmithKline said it settled “to avoid the cost of litigation and disruption”
to their business and that it was not “admission of liability in any way.”
HOSPITALS SUE The Llnited States Supreme Court heard oral arguments recently on a
ON MEDICAID case that may determine whether hospitals can sue states in federal
courts for inadequate Medicaid payments. The case involves the first
of many suits under the Boren Amendment, a 1981 federal law requiring
states to pay the cost of Medicaid patients served by economically and
efficiently operated hospitals. The basis for the first suit, involving the
Virginia Hospital Association and the state of Virginia, is that the state
Medicaid payment system reimburses virtually all hospitals less than
what it costs for inpatient care.
EMPLOYEES PAY MORE According to the Employee Benefit Research Institute, 43 percent of
HEAUH COSTS Americans paid higher monthly premiums in the last two years than in
prior periods. Thirty-two percent paid more for deductibles and 40 per-
cent paid more copayment and dependent coverage amounts. The infor-
mation was derived from a survey of 1,000 individuals.
HOSPITAL BOND This year has proved to be a record year in hospital bond defaults. Bond
DEFAULTS INCREASE Invest°rs Association (BIA), a nonprofit bond tracking agency, has esti-
mated the total default in 1989 to be approximately $190 million. This
SUMMER
RESEARCH
FELLOWSHIP
VOL. 87— NUMBER 4 APRIL 1990
265
MSNJ NEWSLETTER
represents approximately a 50 percent increase over 1988’s $128 million
in defaults. The president of BIA, Richard Lehmann, has stated that
for those hospitals that do not control costs, “time is running out.” On
the contrary, defaults on nursing home debt significantly declined from
$142 million in 1988 to $29 million in 1989. From 1986 to 1989, nursing
home defaults totaled approximately $530 million while hospital defaults
totaled $380 million.
HEALTH CARE
INFLATION
According to the Department of Labor, health care costs increased on
average 8.5 percent for the 12-month period ending December 1989, while
overall inflation only increased 4.6 percent. In addition, the Department
of Labor released the following cost increase data: outpatient services —
increase of 11.7 percent; inpatient services — increase of 11.5 percent;
hospital room fees — increase of 11 percent; prescription drugs — increase
of 9.5 percent; and physician care costs — increase of 7.2 percent (a
decrease of .3 percent from 1988).
HMO PROJECTED
GROWTH
According to Kenneth Abramowitz, a senior analyst with Sanford Ben-
stein & Co., a New York-based investment and management firm,
“HMOs are the only answer.” Mr. Abramowitz is predicting that due
to the health care cost crisis, in the next 20 years all employees will be
forced into health maintenance organizations (HMOs). Fee-for-service
health plans, that covered 89 percent of the private-pay population in
1984, will decline to 10 percent by 1998. Preferred provider organizations
will swing from 1 percent to 35 percent and HMOs will swing from 7
percent to 40 percent during the same period.
PART B PROCESS
APPEALS
Since June 1989, approximately 5,700 requests for a hearing have been
filed and only 21 percent (1,200) have been processed. Based on the
statistics provided by the U.S. General Accounting Office, it is to the
provider’s advantage to appeal in person as the win-rate is 40 percent
versus a 26 percent win-rate for an absentee appeal. The wait period
to appeal-in-person is almost twice as long, at 300 days on the average.
MEDICARE FINAL
PAYMENT RULE
On December 19, 1989, the Omnibus Budget Reconciliation Act of 1989
was enacted. The law maintains the 2.092 percent reduction in payments
under Part A through December 31, 1989, as required under the final
sequester order issued pursuant to the Gramm-Rudman-Hollings Act.
The new law establishes a government- wide sequestration of 1.42 percent
for the period January 1, 1990, to September 30, 1990. However, the Act
also contains a provision that assures that the 1.42 percent sequestration
does not result in a reduction of Medicare Part A payments to hospitals.
Major provisions of the Act also effective for the period January 1, to
September 30, 1990, are as follows:
• Capital costs of inpatient hospital services under PPS are reduced
by 15 percent (sole community hospitals are exempt).
• Rural area PPS rate increases of marketbasket plus 4.22 percent
(9.72 percent above 1989 rates).
• Large urban area PPS rate increases of marketbasket plus .12 per-
cent (5.62 percent above 1989 rates).
• Other urban area PPS rate increases of marketbasket minus .53
percent (4.97 percent above 1989 rate).
• Recomputation of PPS standardized amounts considering budget
neutrality.
• Maintained the 1.22 percent weighting factor reduction for each
DRG provided for in the September 1, 1989, final rule.
SURPLUS FOR
THE BLUES
Douglas Peters, a senior vice-president for the Chicago-based Blue Cross
and Blue Shield Association, predicted that the Association’s 74 health
266
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
plans will report a $1 billion gain in reserves for 1989. This is a significant
turnaround from the $3 billion of losses reported by the plans during
1987 and 1988. According to Peters, the financial improvement allowed
the plans to lower increases in premium rates for subscribers. The Blues
managed care plans, 93 HMOs, and 55 PPOs will show a slight profit
for 1989 compared to a loss of $200 million for 1988.
ROPER TO HEAD CDC
William Roper, MD, will leave his White House post as the President’s
number two domestic policy adviser to become head of the Atlanta-based
Centers for Disease Control (CDC).
MEDICARE
TRUST FUND
In their annual report, the Medicare Trustees claim the Medicare Hospi-
tal Insurance Trust Fund is solvent and in solid financial shape through
1991. Last year, the Trustees indicated that the Trust Fund, that
makes the payments to hospitals for inpatient care, would be solvent
through the turn of the century. According to a report by Roland E. King,
HCFA budget chief, the Trustees’ report relies on overly optimistic
economic assumptions about the national economy.
HMO PREMIUMS
AND PROFITS
A recent survey conducted by the Group Health Association of America
found that HMOs anticipate increasing their premiums during 1990 by
an average of 16 percent. Of the HMOs who responded to the survey,
72 percent said they showed a profit in 1989.
AFFORDING
LONG-TERM CARE
A report issued by Families U.S.A. Foundation and United Seniors
Health Cooperative concluded that only one out of every six elderly
Americans can afford to purchase private long-term care insurance. The
study focused on individual long-term care policies that were offered by
nine leading insurance companies; annual premiums averaged $2,700
and ranged from $1,255 when purchased at age 65 to $3,860 when
purchased at age 79. The Health Insurance Association of America
challenged this data claiming that 40 percent of the elderly can afford
long-term care insurance; however, HIAA used a different criterion for
determining affordability.
HOSPITAL PROFIT ON
HIGH TECH
The Medical Technology and Practice Patterns Institute, using
angioplasty as an example, found that larger teaching hospitals doing
a high volume of specialized procedures earned greater Medicare profits.
MTPPI found 51 percent of the 476 hospitals studied earned a profit
of $59.5 million, while the remaining 49 percent lost $45.3 million. Hospi-
tal costs for angioplasty range from $2,500 to $31,658, with the profitable
facilities earning $2,102 per case and the losers averaging $2,231 per case.
READMISSION REVIEWS
The HHS Office of the Inspector General (OIG) has recommended that
HCFA should challenge the effectiveness of peer review organizations’
scrutiny of hospital readmissions. HCFA annually spends $45 million to
$55 million for PROs to review readmissions; only 1 percent of hospital
readmissions are attributable to premature discharges. OIG recommend-
ed that HCFA consider the effectiveness of random case reviews rather
than reviewing readmissions.
OUTPATIENT SURGERY
INCREASE
Blue Cross and Blue Shield has found that outpatient procedures and
related costs have risen significantly from 1983 through 1988. Outpatient
surgery accounted for 35 percent of all surgery in 1988 compared to 21
percent in 1983. Outpatient costs have increased by 61 percent from 1983
through 1988, with outpatient surgery representing 50 percent of all costs
incurred for surgery.
FINI
“Spring is God’s way of saying one more time.”
VOL. 87— NUMBER 4 APRIL 1990
267
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268
PROFESSIONAL
LI All LIT Y
“There is a widespread problem of mismedication among older adults,”
says U.S. Inspector General (IG) Richard P. Kusserow, in a confidential
January 1989 report entitled, Medicare Drug Utilization Review. Orig-
inally intended to foster development and implementation of an effective
drug utilization review system under the Medicare program, the report
focuses attention on medication-related issues that have significant lia-
bility implications for physicians.
Increased attention to allegations about the mismedication of elderly
patients could result in more malpractice litigation against physicians
and hospitals, and product liability claims against pharmaceutical
manufacturers. Product liability litigation is costly and difficult to de-
fend, as the plaintiffs’ burden of proof is less onerous than it is in other
liability cases. The high costs of litigation and liability insurance have
inhibited research and production of many medications, some of which
have been discontinued. The average indemnity payment in a medi-
cation-related claim against physicians exceeds $40,000; defense costs
are nearly as high.
ELDERLY PATIENTS AT RISK Americans 65 years or older consume 30 percent of the prescription drugs
and 40 percent of the drugs dispensed. In 1986, older adults filled 613
million prescriptions at retail drug stores, an average of 15.5 prescrip-
tions per person.
Although Americans over age 60 comprise roughly 17 percent of the
population, they account for 39 percent of all hospitalizations and 51
percent of deaths resulting from drug reactions. In 1985, an estimated
243,000 older adults required hospitalization due to adverse drug reac-
tions. One study cited in the IG report notes that in 1983, the cost of
hospital and subsequent care related to adverse drug reactions among
the elderly was $4.5 billion. Other estimates of annual health care costs
associated with adverse drug reactions are as high as $7 billion.
The IG report says that 163,000 older adults experience serious mental
impairment either caused or worsened by drugs. In addition, 61,000 older
adults have developed symptoms that mimic Parkinson’s disease due to
prescribed antipsychotic drugs. Two million of the elderly are addicted
or are at risk of addiction to minor tranquilizers or sleeping pills they
use for at least one year. Each year, 32,000 of the elderly incur hip
fractures due to drug-induced falls.
CAUSES OF MISMEDICATION The IG report spreads blame for the mismedication of the elderly among
manufacturers, medical schools, physicians, and patients. The report
notes that although some pharmaceutical products are intended for older
adults, the clinical studies required by the Food and Drug Adminis-
tration (FDA) typically are performed only on healthy young adults. As
a consequence, there is inadequate data about appropriate dosage levels
for older patients or about adverse reactions to the drugs when consumed
by older adults. Only 17 of the 200 most commonly prescribed drugs give
specific geriatric dosage instructions. Although the FDA circulated vol-
MISMEDICATION
OF THE ELDERLY
VOL. 87— NUMBER 4 APRIL 1990
269
PROFESSIONAL LIABILITY
untary guidelines in 1986 for inclusion of the elderly in premarketing
clinical tests, few companies comply.
The Public Citizen Health Research Group, that published Worst Pills,
Best Pills in 1988, studied 287 most commonly prescribed drugs for
nonhospitalized older adults. The study designated 104 of these drugs
(excluding oncology medications) as medications that should not be used
by older adults because safer alternatives are available. Twenty drugs
not recommended for use account for more than 83 million prescriptions
filled for the elderly, at an annual cost of $1 billion. The entire list of
104 drugs in the “do not use” category represents 136 million prescrip-
tions, about a quarter of the prescriptions filled for the elderly annually.
GERIATRIC PHARMACOLOGY Physicians are criticized in the IG report for “widespread prescribing
TRAINING AND PATIENT patterns that are suboptimal for older adults,” practices blamed on
EDUCATION inadequate training and education in geriatric pharmacology. Mis-
medication by physicians can occur in at least four ways, according to
the IG report: (1) higher doses are prescribed when a lower dose would
provide the same benefits with lower risks; (2) drugs with a greater
potential for adverse reactions are prescribed when a less dangerous drug
would be just as effective; (3) the particular drug prescribed is unneces-
sary either because of a misdiagnosis or nondrug therapy could be
substituted; and (4) the combination of the prescribed drug with other
drugs in the patient’s regimen produces adverse effects. Monitoring and
control of medication use by the elderly are complicated by the fact that
85 percent of the elderly patients have one or more chronic illnesses, for
which they take multiple drugs.
In 1988, less than 2 percent of the students enrolled in the nation’s
medical schools were required to take courses in geriatrics. An article
in the January 1988 Annals of Internal Medicine reported that most
medical school students received only one course in pharmacology. By
the time new physicians complete their residency, 100 new drugs have
been introduced. Nearly all prescriptions written in 1988 by physicians
who graduated from medical school in 1960 are for drugs about which
they received no formal education.
Pharmacists are criticized in the IG study for failing to adequately review
patients’ drug regimens or to consult with physicians and patients when
potential problems are identified. Only a small percentage of patients
receive drug counseling services from pharmacists, even in states where
such services are mandated by law. (Studies show that a majority of
physicians do not dispense written information about drugs they
prescribe.)
Older patients are partly to blame for their mismedication problems.
The IG study found that compliance by the elderly with prescribed drug
regimens ranges from 38 percent to 57 percent. Many older patients
under- or overuse medications or share drugs with family and friends.
Noncompliance with drug orders also results from unclear label advice
such as “take as directed.”
ADDRESSING THE The inspector general’s analysis of medication use by the elderly and
MISMEDICATION PROBLEM other studies by the National Council on Patient Information and
Education, senior citizens’ lobbying groups, and various health coalitions
suggest feasible solutions. Kusserow recommends a comprehensive, com-
puterized drug utilization review under the Medicare program to
promote quality of care and reduce costs associated with medication use
and misuse. The program would identify physicians, pharmacists, and
patients who demonstrate patterns of mismedication, and target high-
270
NEW JERSEY MEDICINE
PROFESSIONAL LIABILITY
risk segments of these groups for education efforts. Kusserow requests
a blue ribbon panel to develop drug utilization review criteria and to
make recommendations for expanding medical school curricula in the
areas of pharmacology and geriatrics. In addition, Kusserow urges the
FDA to expeditiously promulgate guidelines to require manufacturers to
ensure adequate testing of drugs on elderly populations.
RISK REDUCTION The following recommendations can assist physicians and other health
SUGGESTIONS professionals to reduce the potential for injury to elderly patients and
lower their own risk of being sued:
1. Take a complete medication history for each patient. Ask about over-
the-counter drugs. Document the patient’s inability to identify drug
names or dosages.
2. Ask the names of all physicians the patient sees and the reasons. Such
questioning may uncover additional medication use the patient over-
looked.
3. Periodically ask and document patient allergies and drug intolerance.
Attach a bright-colored alert to chart covers to call attention to the
allergy information.
4. Carefully monitor prescriptions and refills. Do not permit unlicensed
aides to administer or refill medications without a physician’s specific
approval.
5. Be familiar with indications and contraindications for drugs
prescribed, dispensed, or administered, and know the signs of common
side effects of drugs the patient takes.
6. Write clear instructions for prescription labels.
7. Dispense written information and instructions for medication use.
Printed instructions for most drugs are available from Patient Medi-
cation Instruction Program, U.S.P.C., P.O. Box 5367, Twinbrook Sta-
tion, Rockville, MD 20851; and Drug Use Education Program, American
Academy of Family Physicians, 1740 W. 92nd St., Kansas City, MO
64114.
8. Include periodic pharmacology review in hospital medical staff in-
service programs.
9. Evaluate drug utilization as part of the hospital quality assurance
program. (The Joint Commission reports that 88 percent of the hospitals
surveyed between May 1988 and May 1989 do not fully comply with
standards on drug use evaluation.)
10. Encourage patients to ask questions about prescribed drugs. Ensure
that the patient understands the drug’s purpose, side effects, and con-
traindications. (Reprinted with permission from David Karp, San
Rafael, CA, a professional liability claims consultant. Loss Minimizer,
December 1989.)
PROFESSIONAL James E. George, MD, JD, is director of the Department of Professional
LIABILITY Liability Control, Medical Society of New Jersey, and A. Ronald Rouse
is director of Special Projects, Medical Society of New Jersey.
Please address all comments and concerns to A. Ronald Rouse, Director
of Special Projects, Medical Society of New Jersey, Two Princess Road,
Lawrenceville, NJ 08648. Mr. Rouse also can be reached by calling
609/896-1766, at MSNJ headquarters in Lawrenceville.
VOL. 87— NUMBER 4 APRIL 1990
271
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272
NEW JERSEY MEDICINE
PRESIDENT’S
k PAGE
YOUR PROFESSIONAL Last month, I wrote of the importance to our membership of the Medical
LIABILITY Inter-Insurance Exchange of New Jersey (MIIENJ), founded by the
INSURANCE— II Medical Society of New Jersey, and of the “management company” the
New Jersey State Medical Underwriters, Inc. (NJSMU), wholly owned
by the Medical Society of New Jersey. Our members have been, and
continue to be, well served by “our insurance company.”
Although national statistics show the number of professional liability
cases is trending slightly downward, the size of the verdicts is increasing.
In 1989, six MIIENJ lawsuits resulted in adverse verdicts exceeding one
million dollars each. Although the company is well positioned to meet
such challenges, members of the Board of Directors of NJSMU and of
the Board of Governors of MIIENJ agreed it was time to re-evaluate the
claim management approach and activities.
A special study was authorized, through the consulting firm of Till-
inghast. The consultants performed a thorough review, and have pre-
sented their findings and recommendations. Tillinghast concluded that
top priority should be given to a search for a new president, filling the
position vacated by Peter Sweetland’s retirement due to illness. A search
firm already has been engaged, and the process begun. The study team
also recommended revised policies for claim management, improved
strategies, and several proposals to enhance performance and evaluation.
In addition, the study offered several proposals for improving manage-
ment and Board oversight, to ensure proper control of claim manage-
ment. The recent Tillinghast consultation report will be dealt with
honestly and forthrightly by all involved, and I believe will result in
further improvement of service to our members and to all insureds.
The Board of Trustees recently held the Long-Range Planning Retreat.
Members of the Board met with members of the Committee on Long-
Range Planning and Development to discuss and review the Committee
report.
The Committee chairman, Bernard A. Rineberg, MD, and members of
the Committee, worked with diligence and commitment for over six
months to produce this plan. The fact that they were able to produce
a consistent and outstanding document in so short a time span is a
tribute to their efforts, and to their dedication to this task.
The report will be submitted to the Board of Trustees for approval, and
then will be submitted to the House of Delegates at our 1990 Annual
Meeting.
Of perhaps equal importance to the production of this report was the
process itself. Members of the Board of Trustees had an opportunity to
consider crucial issues, apart from the context and constraints of our
structured Board meetings. The committee members were an invaluable
resource in our deliberations. The senior staff of the Medical Society of
New Jersey also were present, and added further depth to our dis-
LONG-RANGE
PLANNING RETREAT
VOL. 87— NUMBER 4 APRIL 1990
273
PRESIDENT’S PAGE
cussions. In all of this we were aided, and guided, by our facilitator Mark
E. Sandberg, PhD, Associate Dean of the School of Business Adminis-
tration, and Associate Professor of Management and Organizational
Behavior, at Rider College.
The final report of the retreat recommends the process be repeated on
a regular basis, perhaps annually. I know the Medical Society of New
Jersey will benefit from this ongoing process to re-evaluate our goals,
our successes, and our failures.
RETIRING FROM THE Three regular members and two ex-officio members will be retiring from
BOARD OF TRUSTEES the Board of Trustees, at the 1990 Annual Meeting. They are (in
alphabetical order):
• Palma Formica, MD, our immediate past president, and former
chairman of the Board of Trustees, has served in many capacities.
Although leaving our Board, she will continue to provide representation
for New Jersey physicians, and dynamic leadership for the Medical
Society as a member of the AMA Delegation; and she will serve MSNJ
as a member of the Board of Directors of the New Jersey State Medical
Underwriters Inc. Her extraordinary commitment to the medical pro-
fession, and to our patients, is an asset we cherish.
• Edith Goldie, the medical student representative on the Board
of Trustees, attends UMDNJ-Robert Wood Johnson Medical School.
Ms. Goldie has been particularly conscientious in attending our meetings
and participating in our programs.
• Herman Robinson, MD, has been a hard-working, insightful
member of the Board of Trustees, and has chosen to retire from the
Board at this time. He also has served diligently and conscientiously on
the Board of Governors of the Medical Inter-Insurance Exchange of New
Jersey for many years. He recently was elected to the Board of Directors
of the New Jersey State Medical Underwriters Inc. His depth of knowl-
edge will be invaluable in that forum.
• Harold Yood, MD, chairman of the Governing Council of the
Hospital Medical Staff Section, has set a high standard as their first
representative to our Board, this past year. He has long been involved
in MSNJ activities, and will continue to work with the leadership.
• Joseph Zawadsky, MD, also is retiring from the Board at this
time. Dr. Zawadsky’s intelligence and thoughtfulness are well respected.
In addition to his activities with MSNJ, he is the chairman of the
Orthopaedic Department of UMDNJ-Robert Wood Johnson Medical
School, taking this program from inception to maturity. We know he
will continue to play an outstanding role in clinical teaching, research,
and the practice of orthopaedics.
We will miss the wisdom, the experience, and the guidance of our five
colleagues on the Board of Trustees. We are pleased, however, that they
all will continue to serve the medical community, and their patients,
to the betterment of health care in New Jersey. □
274
NEW JERSEY MEDICINE
EDITOR’S
DESK
ODE TO KOOP L.M. Boyd wrote recently, “During the Great Plague of Europe from 1664
to 1666, everybody who could get tobacco smoked tobacco. They thought
it might protect them. It didn’t.” That should have been expected. The
only thing tobacco can protect against is old age — each “coffin nail”
shortens life by a clear and measurable amount. [The list of diseases
associated with smoking continues to grow. It even may be that tobacco
contributes adversely to arthritis, since the plant is a member of the
family, Solanaceae. Research at Rutgers University suggested that food
derived from solanaceous plants might add to arthritic problems.]
Most people know the basic story of tobacco — that it was widely used
by the Indians at the time of Columbus’s voyages, that it was exported
to Europe by explorers from several countries, and that it became a
major crop in the colonies. Some may remember Jean Nicot, French
ambassador to Portugal from 1559 to 1561, who introduced tobacco to
the royal court and whose name was given to the genus as Nicotiana.
Although smoking was considered medicinal with marvelous curative
powers for at least 50 years after its introduction into Europe, some
recognized the deleterious effects of the product. James I, King of Eng-
land, wrote of smoking in 1604, “A custom loathsome to the eye, hateful
to the nose, harmful to the brain, dangerous to the lungs, and in the
black stinking fume thereof, nearest resembling the horrible Stygian
smoke of the pit that is bottomless.”
Despite such warnings, the insidious addictive qualities of tobacco have
continued to enslave millions. In 1988, 5.2 trillion cigarettes were
smoked. It is estimated that worldwide consumption of cigarettes will
grow at a rate of about 1.9 percent a year, a rate higher than the projected
population growth. Louis W. Sullivan, MD, Secretary of Health and
Human Services, released the economic costs of smoking. He lambasted
cigarette producers as “immoral and irresponsible,” as reported in The
New York Times, and added, “Cigarettes are the only legal product that,
when used as intended, cause death.” He accused the tobacco companies
of “trading death for corporate profits.” He estimated the costs for health
care and insurance of smokers and time lost from work at $52 billion
a year — a billion a week. These figures do not include the costs of
“passive smoking,” a topic dealt with so clearly in this issue of NEW
JERSEY MEDICINE (pages 311-317).
It should be quite clear that the costs to the passive smoker, both in
terms of economics and of health, are too great to allow “business as
usual.” All public buildings, including hospitals, should be smoke-free
or, at the very least to accommodate the nicotine addict, have restricted
smoking areas, preferably marked by danger signs — as seen in radiation
areas; a skull and crossbones might also be appropriate. The ban on
smoking in aircraft is sensible; in the future, perhaps, all flights, regard-
less of duration, will have proscriptions attached, or will utilize much
more efficient ways of evacuating and isolating smoke — a project that
also could help the beleaguered restaurateur.
VOL. 87— NUMBER 4 APRIL 1990
277
EDITOR’S DESK
The right of individuals to smoke in private quarters must be main-
tained, within limits; the principle is too elemental and important to
be abrogated. Nonetheless, we can intercede with individuals by per-
suasion and education and bv interdicting the advertising of tobacco
products. That would not be interfering with first amendment rights;
rights should not be enjoyed by those who would entice human beings
to ingest pure poisons, regardless of the “legal” status of those poisons.
But the arrogance of tobacco companies is unlimited. At the same time
the experts in health care in all walks of life and at all governmental
levels are promoting measures to control the deleterious effects of
tobacco, the companies develop programs to expand their market pen-
etration to special groups — women, athletes, minority groups, and the
young. Creating higher purses for professional athletes does not justify
sponsorship and advertising by cigarette companies, and athletes should
stop applauding the merits of this sponsorship.
Can we become a smoke-free society by the year 2000? It may become
more likely, as we continue to expand the rights of the nonsmoker and
smokers find themselves falling into more and more apologetic modes.
Smoking has become a social activity with no redeeming values.
“The believing we do something
when we do nothing is the
first illusion of tobacco. ”
Emerson, Journals , 1859
_____
CONTROLLING TOBACCO The commissioner of environmental protection identified radon as “the
SMOKE POLLUTION most serious environmental health threat to New Jersey residents.”1 He
was wrong. Tobacco smoke pollution kills more people than radon, but
uniquely among pollution problems, effective control saves money.
In this issue of NEW JERSEY MEDICINE, Dr. Ginzel carefully reviews
the evidence that tobacco smoke causes cancer in nonsmokers and
passionately sorts through the implications of this fact (pages 314-317).
In addition to lung cancer in nonsmokers, accumulating evidence in-
dicates that tobacco smoke pollution also causes fatal heart disease in
nonsmokers.2 Over 1,000 deaths per year (mostly from lung cancer and
heart disease) are attributable to tobacco smoke pollution.3
An assortment of laws regulates smoking indoors in New Jersey. These
laws, dating from the early 1980s, have become woefully anachronistic
because of the more recent data Ginzel discusses. The evidence at hand
justifies only one policy for the workplace and for places of public accom-
modation: there should be no smoking indoors.
The Commission on Smoking OR Health has called for revision of the
state’s tobacco smoke pollution control laws along these lines,3 and we
look forward to working with interested officials, legislators, and citizens
to adequately protect the public from New Jersey’s most serious en-
vironmental health threat, tobacco smoke. □ John D. Slade, MD, Com-
mission on Smoking OR Health
REFERENCES
1. Kelly A: DEP: Radon peril is real. The Home News, September 29, 1989,
page A-l.
2. Wells AJ: An estimate of adult mortality in the United States from passive
smoking. Environment International 14:249-265, 1988.
3. Commission on Smoking OR Health: New Jersey's Clean Indoor Air Laws:
A Promise, but Little Protection. New Jersey Department of Health, Trenton,
NJ, May 25, 1989.
278
NEW JERSEY MEDICINE
The Physician: "How
come managed care
always comes down to
managed doctors?"
The Hospital: "Buying the
new technology is tremendously
expensive. But if we want
to provide the best care, how
can we afford not to?"
The Employer: "Why can't
I have a say in my employee's
ealth care? I'm paying for it. "
The Patient: "If I had to
buy my own insurance,
I couldn't afford to get sick. "
VOL. 87— NUMBER 4 APRIL 1990
279
"HEALTH INSURANCE
THAI DOESN'T WORE
FOR EVERYBODY
DOESN'T WORK FOR
ANYBODY."
At the beginning of this decade, nearly all
of the private health insurance in America
consisted of traditional claims/reimbursement
policies. Soon, traditional policies will account
for less than a tenth of all private insurance
- a revolutionary change. The reason? Most
conventional plans haven't met the challenge of
coping with the increasing demand for health-
care services or controlling their rising costs.
Who's behind the rise in healthcare costs?
The answer is: everybody. Americans are
living longer, requiring more (and more
expensive) services. Technology has leaped
ahead-and so have the costs associated with
it. Medical malpractice insurance premiums-
and the marginally necessary tests and proce
dures ordered in anticipation of litigation— adc
billions more to the national healthcare bill.
As a result of these rocketing costs, hospi-
tals, doctors and health plans are facing
unremitting financial pressure. Patients and
employers are letting coverage lapse or
eliminating it altogether. And some of the
answers to the problem are no answer at all:
things like mandated solutions without doctor
involvement or out-of-date reimbursement
schedules.
Doesn't anybody have answers that work?
A half century of health insurance that works.
Fifty years ago, The Medical Society of New
Jersey resolved "to make available to every
man, woman and child of New Jersey ade-
quate personal and sympathetic medical care,
preventive and curative, at the lowest cost
compatible with efficient service." Blue Cross
and Blue Shield of New Jersey believes that
those words made sense back then, and they
still do now. We're not a governmental body,
we're you ... joined together to insure that
Americans receive the best possible care at the
most affordable cost. That's why we're looking
at the entire spectrum of health insurance
options and policies-because today's
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A partnership that works today.
And tomorrow.
One thing we guarantee: We won't be
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we're continuing Medallion' ', the most com-
prehensive plan anywhere. It's why we're
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basic features of Medallion with lower
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Z LETTERS &
VIEWPOINTS
PREVENTION OF According to the National Center For Health Statistics, the number of
HANDGUN DEATHS firearm deaths, including accidental deaths from firearms in the latest
estimate (1987), are 1,649. This is a far cry from the 33,000 that Dr.
Robert Eilers claims in his article, “Prevention of Handgun Deaths.”
Dr. Eilers’s article is a very emotional piece from a man obviously
committed to the banning of firearms in private hands. However, his
argument is colored by emotionalism. There is a number of unsupported
statements such as, “Fatalities due to these causes have been rising at
an epidemic rate.” According to Dr. Eilers, “The most significant factor
associated with the rise in violent deaths that have occurred over the
last two decades has been the tremendous increase in the number of
handguns in the home being used for protection and recreation.” Given
the actual health statistics for firearm deaths — 1,649 — and contrasting
that with a variety of other causes of death, perhaps, may be more
illustrative. For instance, there were 2,674 deaths from surgical and
medical errors; 4,407 deaths from drownings; 4,938 deaths from fires and
flames; 12,001 deaths from falls; 20,520 deaths from homicides and legal
interventions; and, 45,901 deaths from motor vehicle accidents.
From a personal point of view, physicians, as responsible citizens in a
free society, certainly can educate their patients about firearm safety
by directing them to the National Rifle Association (NRA) and other
organizations that run excellent courses in firearm safety that include
such precautions as keeping guns unloaded, locked away, and ammuni-
tion separated from the firearms. From my own personal experience,
having had my son at an NRA-sponsored target shooting club was ex-
tremely helpful and explained the seriousness of that responsibility to
him.
Dr. Eilers makes the assertion that the widespread availability of hand-
guns is “responsible for the increasing rate of violent death in our so-
ciety.” This again is an assertion without any data to back it up. While
Dr. Eilers makes a weak disclaimer about the difficulty in comparing
various societies and their handgun laws, or firearm laws in general, he
still makes that comparison. To refute him, one merely must cite the
experience of the Swiss, where firearms, by law, are kept in each home
as part of the state militia.
When Dr. Eilers reports that the assassination of President Kennedy
took place in 1966 we, of course, know it took place in 1963. He notes
the strict New Jersey gun control laws that have been used in many
communities by the police chief as a de facto way of preventing anyone
from buying a handgun. Most gun owners are aware that delays from
their police department in getting a handgun permit can be inter-
minable. I am sure this meets with Dr. Eilers’s approval, since he is an
advocate of banning the handgun.
For over 55 years, federal laws have prohibited unauthorized possession
of an automatic fire weapon; the laws mandate harsh penalties, includ-
ing prison and heavy fines. Before a weapon is manufactured or imported
VOL. 87— NUMBER 4 APRIL 1990
283
LETTERS & VIEWPOINTS
into the United States, the Bureau of Alcohol, Tobacco, and Firearms
(BATF) Technical Services Department must determine that, in fact,
the rifles cannot be readily converted to automatic fire weapons. There-
fore, there are no assault rifles lawfully held in private hands, except
for specific exclusions that have been approved by BATF for collectors.
Finally, in the interest of intellectual rigor and consistency, I would
expect Dr. Eilers to lead the charge to ban surgical and medical errors,
which produce 1.6 times the deaths per year; recreational swimming,
because drownings produce 2.7 times the deaths; banning of all
poisonous substances, as poisonings are 3.1 times the deaths; and, fi-
nally, an outright ban on motor vehicles since they produce deaths at
a rate of 27.8 times that of firearms.
As a physician and psychiatrist, I am sure it is evident that I disagree
wholeheartedly with Dr. Eilers’s article and do so based upon facts. □
James J. Hutchins, MD
AUTHOR’S
RESPONSE
Coincidentally, a report released from NCHS since my article appeared
looked at the 1987 data specifically and found an increasing number of
deaths from firearms now involve children and teenagers. In fact, a
majority of the 1,649 deaths that he cites involve children playing with
guns rather than hunting accidents as was the case in previous years.
Equally tragic is the fact that the greatest recent increase in firearm-
associated death rates was for teenagers occurring as a result of homicide
and that guns accounted for about one in every ten deaths of children
and teenagers.
If this is not enough evidence to convince Dr. Hutchins that firearm
violence is epidemic in the country, he should read reports from the
Surgeon General, the American Medical Association, the American
Academy of Pediatrics, and the Centers for Disease Control, all of whom
have made similiar statements and are referenced in my article. Dr.
Hutchins’s computations regarding the risk of firearm deaths compared
to mortality from other activities are in error because of his mis-
understanding of the NCHS database. When he implies that our society
would never consider restricting personal freedoms such as these in order
to save lives, he should consider current laws that bar hazardous prod-
ucts or otherwise protect the public’s health. In regards driving, for
example, there are laws requiring child safety restraints, seat belts, and
speed limits. Certainly, the licensing requirements for driving are much
more severe than those that currently exist for gun purchases.
Dr. Hutchins believes that it is far more preferable to educate the public
about gun safety than to restrict gun ownership. However, his approach
would have little impact on the vast majority of firearm injuries and
deaths since these are not due to accidents but are intentional acts.
Dr. Hutchins appears to be eager to find errors in my article to the point
of trying to make the reader believe that neither the editors nor I knew
the year of President Kennedy’s death, even though the article clearly
states that the 1966 New Jersey gun law was passed “in the wake of
the Kennedy assassination.” However, it is Dr. Hutchins who has erred
in his utilization of the 1987 mortality data from the National Center
for Health Statistics (NCHS), which he states lists 1,649 firearm deaths.
The NCHS compiles its data from death certificates filed with local
health authorities. The statistics listing nonintentional firearm deaths
is the figure Dr. Hutchins cites. This statistic does not include the far
greater numbers of deaths that are intentional (suicide and homicide)
deaths, that are listed as “firearm related.”
284
NEW JERSEY MEDICINE
LETTERS & VIEWPOINTS
Although the numbers of nonintentional deaths have decreased in recent
years, this is probably not a result of educational efforts, but the result
of greater accuracy in the classifications of firearm suicides. In fact,
studies suggest that the benefits of gun safety courses must be balanced
against their ability to promote an interest in firearms, which increases
the number of firearms in possession and their potential for causing
death. Despite such education, a large segment of the public still keeps
their handguns unsecured in their homes and many persons keep hand-
guns loaded, even when children are in the household.
While Dr. Hutchins should be commended for teaching his son about
gun safety, his mention of the NRA’s efforts requires some comment.
The NRA is spending an ever-decreasing proportion of its funds on gun
safety education as it increases its outlays on lobbying efforts against
any type of government restriction on firearms, whether these be con-
cerned with assault weapons or the banning of bullets capable of piercing
police vests. Dr. Hutchins states an NRA position when he attempts to
confuse this issue by equating all assault rifles with the already banned
automatic weapon. Fortunately, the public no longer believes some of
the NRA’s lobbying efforts. According to a recent poll commissioned by
Time and CNN, a majority of gun owners favor a waiting period for the
purchase of firearms. Hopefully, physicians will be in the forefront for
leading the call for such initiatives in order to deal with this major public
health problem. □ Robert Eilers, MD
MEDICATION I want to congratulate NEW JERSEY MEDICINE on the excellent
ERRORS paper on medication errors (87:27-34) published in the January issue.
I think this type of study is most useful to all practicing physicians who
are concerned with the malpractice situation.
In the past ten years, I have performed some 250 medical/legal exami-
nations as a neurologist for large law firms in New York City who are
defending doctors and hospitals from malpractice claims. I currently am
evaluating these cases and hope to learn something useful that may help
other practitioners. I began this study several weeks ago after seeing two
patients within a relatively short time frame, who were totally in-
capacitated by complaints that had no anatomical basis. This peaked
my interest and eventually led me to Henry Miller’s excellent articles
in the British Medical Journal in 1961. As I analyze these cases, I think
I am seeing what he saw, namely a significant number of “accident
neuroses,” except here they are all medical/legal in nature. In any event,
it is challenging to study this problem that concerns us all so much.
I maintain an office in Ridgewood, where I see patients two days per
week. Most of my practice is at the Neurological Institute in New York
City. □ Frank K. Boschenstein, MD
LETTERS TO Letters to the editor are welcome. The editor-in-chief will review all
THE EDITOR comments on articles published in NEW JERSEY MEDICINE, as well
as concerns for the physician community and the health care industry.
Please address letters to Howard D. Slobodien, MD, Editor-in-Chief,
NEW JERSEY MEDICINE, Two Princess Road, Lawrenceville, NJ
08648. □
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286
NEW JERSEY MEDICINE
BOOK
REVIEWS
BASIC BIOMECHANICS Margareta Nordin and Victor H. Frankel. Philadelphia, PA, Lea &
OF THE Febiger, 1989. The second edition of this gold-standard text is a must
MUSCULOSKELETAL ^or orthopedists, physical and occupational therapists, and other health
gygygjyi professionals who deal with musculoskeletal disorders. The new edition
adds chapters on the cervical spine, wrist, and hand. The chapter on
biomechanics of the hand is a paradigm of clarity for this usually com-
plex subject.
Five chapters deal with tissues and structures; the following ten chapters
discuss mechanics, joint by joint. An introductory chapter gives a good
overview of the metric system, including a conversion table. At the end
of each chapter, its chief concepts are succinctly summarized, followed
by a bibliography and recommendations for further reading. There is a
comprehensive, easily understood glossary and a complete index.
Although a degree in engineering is not a prerequisite for understanding
this book, a fundamental knowledge of a simple algebra and plane
trigonometry is helpful. Mechanics is a quantitative science and would
be unintelligible without numbers. The math, however, is presented
clearly. Practical examples show how biomechanical concepts are ap-
plied clinically. Some of the photographs are too dark, but the more
important illustrations are clear line drawings and uncluttered graphs.
Doctors Nordin and Frankel are from the Hospital for Joint Diseases in
New York; orthopedist Frankel has devoted his life’s work to this subject.
Although there was an international roster of contributors, the book is
not infected with a multiauthor syndrome. The authors have compiled
another lucid and essential treatise. □ Richard M. Ball, MD
CHILDREN WITH Thomas F. Plaut, MD. Amherst, MA, Pedipress, Inc., 1988. Asthma is
ASTHMA. A MANUAL the leading cause of pediatric hospital admissions and is responsible for
FOR PARENTS the lar&est number of missed school days. More than three million
children have asthma, and the frequency is increasing. In addition,
asthma mortality is on the rise, despite new management.
The foundation of asthma management must be the education of the
pediatric patient and parents. The second edition of Children With
Asthma proves to be an excellent information source. Pathology, physiol-
ogy, asthma diaries, medications, and home treatments are covered
thoroughly in lay terms with good illustrations. In particular, Dr. Plaut
stresses the use of home peak flow meters, holding chambers with in-
haled medications, and the use of an asthma record. By teaching pa-
tients to control symptoms, children can continue a normal lifestyle.
There also is a resource list including books, asthma organizations,
newsletters, videotapes, and equipment vendors. The book covers many
common potential problems including babysitters, school, and travel.
This book emphasizes the team approach. It serves as an excellent
education and reference source, and is highly recommended to the
parents of children with asthma. □ Andrew Pedinoff, MD
BOOK REVIEWS
CLINICAL CARDIOLOGY, Peter C. Gazes, MD. Philadelphia, PA, Lea & Febiger, 1990. Arguably,
THIRD EDITION what most medical libraries need least is another textbook on clinical
cardiology. Yet, Dr. Gazes’s book is exceptional in that it represents the
personal experience of a single author. As such, the textbook is free of
the redundancies and inconsistencies of the more popular multiauthored
tomes, but it suffers from certain opinionated statements and outdated
concepts.
The third edition has been extensively rewritten in an effort to reflect
the explosive developments in clinical cardiology, but some areas lag
behind. For example, newer techniques in interventional cardiology such
as atherectomy and angioscopy are not described, and Dr. Norwood
would be chagrined to discover that “no corrective operative procedure”
exists for the hypoplastic left heart syndrome (page 286). While the
chapter on “arrhythmias” generally is excellent, there is scant mention
of the role of invasive studies (EPS) in diagnosis and management
(chapter 15).
Some of the terminology is archaic, e.g. transmural and subendocardial
infarction (page 57), types A and B Wolff-Parkinson-White syndrome
(page 58), and the classification of unstable angina (Table 4-2). Most
would argue with Dr. Gazes that electrical alternans does not have the
same significance as pulsus alternans (page 58) and that electrocardio-
gram (EGG) clockwise rotation of the heart does not relate to anatomical
rotation (page 36).
On the other hand, this distinguished cardiologist contributes excellent
discussions of the cardiovascular examination, diagnostic clues in
cardiovascular disease, noncardiac surgery in cardiac patients, and an
appendix for usual doses of cardioactive drugs. Notwithstanding the
minor criticisms, I recommend this book to students, house officers, and
even experienced cardiologists, especially those who are weary of
burdensome multiauthored texts. □ Edwin L. Rothfeld, MD
HODGKIN’S DISEASE: Mortimer J. Lacher, MD, and John R. Redman, MD. Philadelphia, PA,
THE CONSEQUENCES Lea & Febiger, 1990. Medical progress often comes at a price; in the
OF SURVIVAL case Hodgkin’s disease, advances in treatment effectiveness have
resulted in late or long-term sequelae that have raised new challenges
in the quest for mastery over this complex and still poorly understood
illness.
Lacher and Redman, both lifetime students of Hodgkin’s disease, and
35 other outstanding clinicians and investigators provide the reader with
considerable insight into the myriad of sequelae pertaining to Hodgkin’s
disease itself as well as to treatment-related effects.
Considerations range from the epidemiology of second primary cancers
to the late effects of chemotherapy and radiation, and include the pan-
orama of infectious complications eventuating from induced immunoin-
competence. Specific organ-site complications are recognized, in particu-
lar cardiovascular, pulmonary, gastrointestinal, renal, skeletal, and
dental. Particular problems associated with pregnancy and progeny and
the long-term psychosocial consequences are highlighted in this 1990
textbook.
The book is well organized, reads easily, and is thoroughly cross-refer-
enced. Although substantial progress has been made in the effectiveness
of treatment for Hodgkin’s disease, we are kept mindful of the important
iatrogenic factors that bear upon a successful outcome for this disease.
□ Alan J. Lippman, MD
9RR
Long Odyssey of
Babesiosis
SANDRA W. MOSS, MD
The history of babesiosis is traced from the discovery of the parasite in 1888,
to its present endemic niche. The author uncovers clinical and
epidemiological features of human babesiosis in a patient hospitalized in
New Jersey.
Babesiosis is a malaria-like disease caused by
the intraerythrocytic parasite, Babesia. It is
endemic to Nantucket and other islands off
the northeastern United States. The international
odyssey that led to the identification and under-
standing of clinical babesiosis in the United States
climaxed in New Brunswick, New Jersey in 1969.
The story of babesiosis began in Romania in 1888,
moved to Texas in 1889, and then to Montana in
1902. There was silence until 1956 when the trail was
picked up in Zagreb, Yugoslavia. From there, it de-
toured briefly to California and then to Ireland. In
1969, an alert hematology technician and three phy-
sicians in New Brunswick discovered the clue that
set the National Communicable Disease Center in
Atlanta on the correct trail to Nantucket.
Romania. In 1888, Victor Babes of Romania dis-
covered a small protozoan in the blood of sheep
Dr. Moss is affiliated with the Department of Internal
Medicine, Rutgers Community Health Plan, New Bruns-
wick, and is a clinical associate professor, UMDNJ-Rob-
ert Wood Johnson University Hospital, New Brunswick.
Requests for reprints may be addressed to Dr. Moss,
RCHP, 312 Pierson Avenue, Edison, NJ 08837.
suffering from an epizootic disease called “carceag.”
The genus was named Babesia in his honor, but it
also is known as Piroplasma (referring to its pear
shape). A similar parasite was found by Babes to be
the cause of hemoglobinurie fever of cattle. Seventy-
one species of Babesia have been discovered, and are
responsible for infections in cattle, sheep, dogs, cats,
horses, rodents, goats, and birds. Species such as B.
microti (the most common cause of endemic human
babesiosis), that parasitize rodents, assume
amoeboid or ring forms, and can be mistaken for
Plasmodium falciparum (malaria) by inexperienced
observers. However, unlike the malaria parasite,
Babesia does not produce pigment granules in the
infected erythrocytes.
Texas. In 1889, the American bacteriologist
Theobald Smith went to Texas to study a livestock
disease called “redwater fever” (Texas cattle fever).
Smith found B. bigemina in the affected animals.
More importantly, he proved that Texas fever is
transmitted by ticks. Cattle babesiosis was the first
disease in which an arthropod vector was recognized.
Montana. In 1902 and 1903, intracellular para-
sites were identified in the blood smears of 18 people
VOL. 87— NUMBER 4 APRIL 1990
291
from the Bitter Root Valley who were suffering from
“spotted fever.” Over 100 other victims did not have
parasitemia. The illness was severe and frequently
fatal. The parasites were identified as members of
the Piroplasma (Babesia) genus. Tick bites often
were found on the victims. The researchers con-
cluded incorrectly that what now is known as Rocky
Mountain spotted fever (a rickettsial disease) was
caused by the Babesia parasite; they proposed the
name “piroplasmosis hominis” for the disease, then
known as “spotted fever.” In retrospect, it is evident
that some of the cases were Rocky Mountain spotted
fever, and other cases, quite possibly, were human
babesiosis. However, by modern standards, the
Montana series lacks sufficient documentation for a
clear diagnosis of human babesiosis.1
Yugoslavia. Human babesiosis resurfaced in the
medical literature over 50 years later in a European
publication called Documenta de Medicina Geo-
graphiea et Tropica . 2 A 33-year-old tailor from
Strmec, Yugoslavia, was admitted to the Depart-
ment of Medicine at the University of Zagreb on
June 16, 1956, in critical condition. He had an eight-
day history of malaise, fatigue, and anorexia, with
the subsequent onset of gross hematuria, abdominal
pain, and headache. In 1945, he had undergone
splenectomy for injuries suffered in an automobile
accident. He never had been to the malarial area of
Yugoslavia. He drank one litre of “spirits” daily and
often was intoxicated. On admission, he had fever,
anemia, and hemoglobinuria. By June 17, he was
completely anuric. The diagnosis was assumed to be
acute hemolytic anemia of the idiopathic or second-
ary type and he was treated with penicillin, strep-
tomycin, and cortisone. He died on hospital day 2.
The blood smear showed “multiple tiny extended
rings and rods in the erythrocytes, especially the
hemolyzed ones.” These parasites subsequently were
identified as B. bovis.
Figure 1. Blood smear from the patient, hospitalized in New
Brunswick, in 1967. Parasitized Babesia microti are present in
several erythrocytes. A tetrad form is seen within one of the
cells. (From the collection of Dr. Vincent Galdi.)
The Yugoslav group conducted a small-scale
epidemiological study and found that cattle near the
patient’s rural home had contracted babesiosis a
fortnight before the onset of the patient’s illness.
Furthermore, in the local fields where the patient
often grazed his cattle, there were many ticks of the
type known to transmit babesiosis in cattle.
The investigators concluded with considerable in-
sight: “Experiments on animals have shown that
after experimental splenectomy infection with
piroplasmata causes a very grave disease leading to
the death of most animals. . . . VVe suppose therefore
that a ‘biological experiment’ with fatal outcome
took place in our patient due to the splenectomy.”2
California. All was quiet for 11 years, until a case
was reported from California.1 A 46-year-old
amateur photographer, who took hikes into the
isolated coastal areas near San Francisco, became ill
with symptoms consistent with malaria. He had a
past history of splenectomy for hereditary
spherocytosis. He was treated for presumptive
malaria with chloroquine for 15 weeks and re-
covered. His original blood smear showed parasites
similar, but not identical, to Plasmodium. Anti-
bodies to Babesia were found in his blood. The
Babesia species remains unknown.
Ireland. The third human case was recognized in
Ireland and was reported one year later in the British
Medical Journal. The article begins with a quote
from Exodus (9:3): “The fifth plague: ‘Behold the
hand of the Lord is upon thy cattle which is in the
field, upon the horses, upon the asses, upon the
camels, upon the oxen and upon the sheep: there
shall be a very grievous murrain.’ ”'1 In parts of Ire-
land, “murrain” is synonymous with “redwater” in
cattle.
A 47-year-old fisherman was hospitalized in
Downpatrick with a four-day history of hematuria,
nausea and vomiting, anorexia, and high fever. His
hemoglobin fell to 7.2 g/dl and there was evidence
of gross hemolysis. Past history included surgery sev-
eral months earlier for perforated duodenal ulcer
requiring multiple transfusions. The spleen had
been torn during surgery and a splenectomy had
been performed. He was transferred, shocky and
moribund, to Belfast City Hospital. Intraeryth-
rocytic parasites were seen on the blood smear and
the working diagnosis was malaria due to P.
falciparum, possibly acquired from the earlier trans-
fusions. Peritoneal dialysis was performed. Ex-
change transfusion was planned, but he died three
days after admission.
Interviews with the family revealed that the pa-
tient had been in County Galway on a camping
vacation, where redwater fever was known to be
present in cattle. All the blood donors from his
earlier surgery were traced and found to be negative
292
NEW JERSEY MEDICINE
Figure 2. St. Peter's Medical Center, New Brunswick, as it ap-
peared in the 1960s. The present-day St. Peter's Medical Center
has been redesigned and expanded.
for malaria. A reference laboratory subsequently
identified the parasite as B. divergens.
In a subsequent investigation, British researchers
tried to determine whether normal people living in
tick-infested areas of Ireland had latent infections
identifiable by blood testing. Although inconclusive,
the study was memorable for the unusual method
of recruiting experimental subjects. As the re-
searchers approached the suspected rural site in Gal-
way, they discovered a large number of Irish Army
troops participating as extras in the Metro-Gold-
wyn-Mayer spectacle, Alfred the Great, filming “on
location” in Ireland. The soldiers had been camped
in the tick-infested fields for two weeks and volun-
teered to donate blood for the babesiosis study."
New Brunswick, New Jersey. In July 1969, Dr.
Benjamin Glasser, a colon and rectal surgeon from
New Brunswick, received a long-distance telephone
call from Nantucket. The caller, whose relatives had
been cared for by Dr. Glasser, implored him to come
to the assistance of a middle-aged Nantucket neigh-
bor, who appeared to be dying. Dr. Glasser flew to
Nantucket in a private airplane provided by the
friend of the sick woman. The patient, who had
remained undiagnosed in Massachusetts, told Dr.
Glasser she wanted to die at home. He proposed an
alternate plan: immediate transfer to St. Peter’s
Medical Center in New Brunswick. Accompanied on
the private airplane by Dr. Glasser, the patient ar-
rived at St. Peter’s Medical Center on July 13, 1969.
Physical findings at the hospital were normal except
for fever and pallor.6
The case report, that subsequently appeared in
The New England Journal of Medicine indicated the
patient, a 59-year-old woman, had a two-week his-
tory of fever, headache, and crampy abdominal
pain/ She previously had been in excellent health
and had no history of splenectomy. Two months
prior to admission, she had left Santa Barbara, Cali-
fornia, for her summer home on Nantucket Island.
Her dachshund often chased and caught small ro-
dents near her cottage. Aware that ticks were com-
mon in the area, the patient examined her dog daily
and removed ticks with tweezers or her fingers. She
also had removed one tick from her own suprasternal
notch.
An alert laboratory technician found the correct
clue the next morning: While routinely examining
the blood smear, Marie Hahn noted intracellular
bodies resembling malaria.8
Dr. Vincent Galdi, Director of Laboratories at St.
Peter’s Medical Center, recalls the case: “My in-
volvement with the case began as follows: Marie
Hahn came to me to review a blood smear which,
according to her, contained malaria parasites. I
looked, and I agreed with the presence of malarial
parasites, all in ring form. The attending physician
was notified and, shortly thereafter, Dr. Benson,
professor at the medical school, came to look at the
malarial parasites.”9
Dr. Gordon D. Benson, currently chief, Division
of Gastroenterology and Liver Diseases at the Llni-
versity of Medicine and Dentistry of New Jersey in
Camden, noted: “I was asked to see the patient in
consultation because someone thought I knew some-
thing about malaria. After my initial evaluation, I
telephoned the Department of Health in Massachu-
setts. They did not seem to be particularly interested
in the problem so I made contact with the Parasitic
Diseases Branch of the National Communicable Dis-
ease Center in Atlanta. They were quite interested
and were particularly helpful. The blood smears
were sent to them for review.”10
On July 18, an internal memorandum was sent
from the chief of the Parasitic Diseases Branch to
the director of the National Communicable Disease
Center (now the Centers for Disease Control). The
subject of the memorandum was “Cryptic Para-
sitemia— New Jersey.” After duly noting Dr.
Benson’s phone call and the receipt of the slides, the
memorandum recorded the finding of ring forms
consistent with malaria. Further study of the “dis-
tinct quadranucleated ‘Maltese Cross’ intraeryth-
rocytic bodies” led to a final diagnosis of Babesia sp.
Dr. Ronald Altman, state epidemiologist, New Jer-
sey State Department of Health, was contacted and
agreed with plans for a clinical and epidemiologic
investigation. On July 18, Dr. Karl Webster, chief,
Malaria Surveillance, Parasitic Diseases Branch,
and Dr. Arthur Dover, epidemic intelligence service
officer, Parasitic Diseases Branch, left Atlanta for
New Brunswick."
Dr. Galdi and Dr. Benson recall that the actual
recognition of Babesia was made by Neva Gleason,
a laboratory technologist at the Communicable Dis-
ease Center, who also had recognized Babesia in the
California case one year earlier. The species isolated
VOL. 87— NUMBER 4 APRIL 1990
293
in New Brunswick was determined to be B. microti.
The patient’s blood was sent to Atlanta for further
study; infection was established in laboratory
animals. Acute and convalescent sera were used for
antibody studies.
Marie Hahn recalls interest in the case ran very
high at St. Peter’s Medical Center, where slides of
the blood smears were left out on the laboratory
bench for interested visitors to examine. The Com-
municable Disease Center brought the case to na-
tional attention in its Morbidity and Mortality
Weekly Report on August 15, 1969.
Chloroquine was prescribed for the patient on hos-
pital day 2, while the diagnosis of malaria still was
being considered. Once babesiosis was identified,
chloroquine was continued. The patient improved
over a period of seven to ten days and eventually
made a full recovery, returning to her home in Nan-
tucket. Dr. Glasser maintained contact with her
until her death from carcinoma several years ago.
Nantucket. The epidemiology of babesiosis was
uncovered as a result of the National Communicable
Disease Center’s interest in the New Brunswick case.
Ticks of the Ixodes genus transmit babesiosis. On
Nantucket, the previously unknown species called
Ixodes dammini (named in honor of Gustave Dam-
min, a Harvard Medical School pathologist) was
identified as the carrier of endemic babesiosis. The
most common tick reservoir is the white-footed
mouse (Peromyscus leucopus), although a variety of
other species, including the white-tailed deer, are
also reservoir hosts. In referring to the pre-adult
stage of the tick life cycle, Robert Desowitz aptly
dubbed them “the dangerous nymphs of Nan-
tucket.”12
By 1977, approximately 25 cases of babesiosis had
been reported from Nantucket, and the name “Nan-
tucket fever” was found in the medical literature1'1 2 3 4 5 6 7
as well as the popular press. 14 By 1980, close to 100
cases of Babesia microti infection had been reported
in the United States. The endemic area was largely
confined to the coastal islands of Massachusetts and
New York.
In 1977, a serologic survey of visitors to Nantucket
as well as residents of the island was undertaken.15
Approximately 2 percent of people undergoing rou-
tine diagnostic studies at Nantucket Hospital had
B. microti antibody titers. However, only about one-
third of those with evidence of exposure to Babesia
had a history of a febrile illness. This study proved
that infection with B. microti may be asymptomatic
or characterized by mild and self-limited symptoms.
Some victims develop a moderately severe and de-
bilitating illness characterized by fever, chills,
malaise, myalgias, and hemolytic anemia. Therapy
may be supportive or may include chloroquine and,
recently, pentamidine. In splenectomized patients,
the disease can be fatal.
CONCLUSION
Human babesiosis is a parasitic infection with a
long and colorful international history. Although the
disease in the United States is endemic to Nan-
tucket Island, Massachusetts, the key step in identi-
fying the illness and its etiology took place in 1969
at St. Peter’s Medical Center in New Brunswick.
The New Brunswick case was important because it
led to the recognition of an endemic parasitic disease
in the northeastern United States. It also was the
first case of babesiosis involving a patient with an
intact spleen. It led to the development of diagnostic
tests for the disease and a vigorous epidemiological
interest in human babesiosis.
Three New Jersey physicians — a colon and rectal
surgeon, a hospital pathologist, and a gastroenter-
ologist— together with an observant hematology
technician, gave New Brunswick a significant place
in the history of parasitology. ■
Submitted: September 1989;
Accepted: November 1989
REFERENCES
1. Wilson LB, Chowning WM: Studies in pyroplasmo-
sis hominis (“spotted fever” or “tick fever” of the Rocky
Mountains). J Infect Dis 1:31-57, 1904.
2. Skrabalo Z, Deanovic Z: Piroplasmosis in man. Doc
de Med Georgr et Trop 9:11-16, 1957.
3. Scholtens RG, et al.: A case of babesiosis in man
in the United States, ,4m J Trop Med Hyg 17:810-813,
1968.
4. Fitzpatrick JEP, Kennedy CC, McGeown MG, et
al.: Further details of third recorded case of redwater
(babesiosis) in man. Br Med J 4:770-772, 1969.
5. Garnham P, Donnelly J, Hoogstraal H, et al.:
Human babesiosis in Ireland. Br Med J 4:768-770, 1969.
6. Glasser, B: Personal communication.
7. Western K, Benson G, Gleason N, et al.: Babesiosis
in a Massachusetts resident. N Engl J Med 283:854-856,
1970.
8. Hahn M: Personal communication.
9. Galdi V: Personal communication.
10. Benson GD: Personal communication.
11. Schultz MG: Cryptic parasitemia — New Jersey.
Public Health Service Memo, NCDC, Atlanta. July 18,
1969.
12. Desowitz RS: New Guinea Tapeworms and Jewish
Grandmothers. New York, NY, W.W. Norton, 1981.
13. Scharfman WB, Taft EG: Nantucket fever: An ad-
ditional case of babesiosis. JAMA 238:1281-1282, 1977.
14. Altman LK: Malaria-like disease diagnosed in two
on Long Island. The New York Times. New York, NY,
September 25, 1977.
15. Reubush TK, Juranek DD, Chisholm ES, et al.:
Human babesiosis on Nantucket Island: Evidence for self-
limited and subclinical infections. N Engl J Med
297:825-827, 1977.
294
NE^JERSE^MEDICI^
CASE REPORT
Cancer Recurrent at
Stapled Colon Incision
J. THOMAS DAVIDSON, MD
LUCIUS D. CLAY, III, MD
MICHAEL UMANOFF, MD
JAMES J. CHANDLER, MD
Recurrence of colon cancer at a stapled colotomy site separate from the
anastomosis was discovered through a rising carcinoembryonic antigen
(CEA). Resection resulted in cure. Exfoliation and implantation of cancer cells
is discussed.
No significant increase in survival or alter-
ation in recurrence rates has been obtained
in the treatment of colorectal carcinoma.1,2
Surgical intervention affords patients the only
chance for long-term survival. Accepted surgical
standards include resection of the lesion with ap-
propriate margins and with the lymphatic drainage
basin. Other recommendations incorporate aspects
of the so-called no-touch technique as expounded by
Barnes and Turnbull and include high ligation of the
vascular structures, isolation of the lesion by proxi-
mal and distal ligation of the colon, avoidance of
manipulation, and use of intraluminal irrigation.3,4
Although these measures carry no proven benefit,
they place importance on the ability of tumor cells
to exfoliate, to remain viable, and, theoretically, to
implant. Bowel continuity can be re-established
with a handsewn or stapled anastamosis. Some tech-
niques with the end-to-end stapling instrument
utilize a separate incision for introduction of the
stapler.5,6 This report concerns implantation of co-
lonic cancer cells at colotomy site.
A 43-year-old white woman presented with an ob-
structing left colon carcinoma and underwent
emergency transverse colostomy followed later by a
Drs. Davidson, Clay, Umanoff, and Chandler are affiliated
with The Medical Center at Princeton. Requests for re-
prints may be addressed to Dr. Clay, The Medical Center
at Princeton, NJ 08540.
left hemicolectomy. At the latter operation, a colonic
carcinoma was found at the junction of the descend-
ing and sigmoid colon. This transmural tumor in-
volved the lateral pelvic wall, the broad ligament,
and the uterine cornu. A total abdominal hys-
terectomy and bilateral salpingo-oophorectomy was
carried out at the same operation. Bowel continuity
was restored using the end-to-end anastomosis
(EEA) stapler introduced via a proximal colotomy.
The colotomy was closed with a TA-55 stapling in-
strument. The pathologist diagnosed a moderately
well-differentiated adenocarcinoma of the colon.
Tumor involvement was found in two regional
lymph nodes.
Postoperatively, the patient received 5,000 rads of
cobalt 60 radiotherapy to the area of extra-intestinal
extension and one year of systemic 5 fluorouracil.
Five months after chemotherapy was stopped, a rise
in the patient’s serum carcinoembryonic antigen
(CEA) level was noted. Radiographic and en-
doscopic evaluation failed to reveal recurrent dis-
ease, and a second-look exploratory laparotomy was
performed. At operation, a recurrent tumor was
found on the serosal surface of the colon where the
colotomy had been closed. A segmental resection
was carried out. No other area of disease was noted.
Pathological analysis confirmed that the tumor was
limited to the serosal aspect of the bowel, without
transmural extension, and histopathology was simi-
lar to that of the original tumor.
CASE REPORT
Exfoliation, continued cell viability, and subse-
quent implantation of tumor cells as a cause of distal
or suture line recurrence have remained a con-
troversial subject. Some surgeons believe such in-
stances of recurrence represent residual disease."
Many authors, however, have reported large
numbers of exfoliated cells within the intestinal
lumen.81'1 2 3 The ability of these cells to remain viable
has been demonstrated by Umpleby and associates.8 9 10
Implantation of these tumor cells never has been
proved conclusively, but there are many publi-
cations alluding to this as a plausible mechanism of
recurrence.11 It is believed that intact colorectal
mucosa acts as a barrier to tumor spread and that
areas of mucosal damage form nutrient beds for im-
plantation.111 In view of this, suture lines, anal fis-
sures, anal fistulas, hemorrhoidectomy sites,
cecostomies, and other areas of mucosal injury may
serve as beds for implantation and recurrence.1218
In the case reported, it appears implantation at
the time of the original anastomosis caused the
subsequent recurrent tumor. The location of the re-
current tumor at the proximal colotomy site would
seem to imply that the tumor cells were implanted
when the stapling device was withdrawn through the
colotomy. Closure with TA-55 stapler results in
everting staple line; this would account for the lo-
cation of this recurrent tumor on the serosal surface.
Turnbull proposed a “no-touch” technique: limit-
ing tumor manipulation, ligating the bowel proximal
and distal to the tumor, and obtaining vascular con-
trol prior to mobilization of the bowel. This would
theoretically reduce the incidence of lymphatic,
vascular, and intraluminal spread of tumor cells.
Additionally, Turnbull suggested the use of in-
traluminal irrigation or instillation of tumoricidal
agents to reduce the number of free viable cells.4 5 6 7 But
significant improvement in survival statistics never
has been documented clearly with the use of the no- j
touch technique. Tumor cell implantation is uncom-
mon. Nonetheless, many instances of local or
anastomotic recurrence can be attributed to this
mechanism. Distal recurrences also have been at-
tributed to circular staplers when passed through
the rectum from below.12 Larger series, however,
document that the use of end-to-end staplers for low
anterior resections has not resulted in an unusually
high incidence of local recurrence.19 The advantage
of obtaining a low anastomosis and the preservation
of sphincter function after resection of low-lying
lesions outweighs the risk of this rare occurrence.
In treating more proximal lesions, it is reasonable
to incorporate surgical techniques which minimize
the possiblity of implantation. Specifically, when
using stapling devices, it would seem appropriate to
avoid the use of the proximal colotomy for introduc-
tion of the circular stapling device. The colotomy
adds an extra suture line at risk for implantation as
well as for other complications. Intraluminal irriga-
tion and early ligation of the bowel lumen do not add
a great deal of time or complexity to colon resections
and also should be utilized when feasible. ■
Submitted: March 1989;
Accepted: December 1989
REFERENCES
1. American Cancer Society: Cancer statistics 1986:
CA-A. Cancer J Clinicians 36:9-25, 1986.
2. Welch JP, Donaldson GA: Recent experience in the
management of cancer of the colon and rectum. Am J Surg
127:258-266, 1974.
3. Barnes JP: Physiologic resection of the right colon.
Surg Gynecol Obstet 94:723-726, 1952.
4. Turnbull RB Jr, Kyle K, Watson FR, Spratt J:
Cancer of the colon. Ann Surg 166:420-427, 1967.
5. LeBlanc KA, Russo VR: Modification of the end-to-
end stapled anastomosis utilizing intersecting staple lines.
Arch Surg 123:110-112, 1988.
6. Nance FC: New techniques of gastrointestinal anas-
tomosis with the EEA stapler. Ann Surg 587-600, 1979.
7. Rosenberg IL, Russell CW, Giles GR: Cell viability
studies on the exfoliated colonic cancer cell. Br J Surg
65-188-90, 1978.
8. Umpleby HC, Fermon B, Symes MD, Williamson
RCN: Viability of exfoliated colorectal carcinoma cells. Br
J Surg 71:659-663, 1984.
9. Vink M: Local recurrence of cancer in the large
bowel. Br J Surg 41:431-433, 1954.
10. McGrew EA, Laws JF, Cole WH: Free malignant
cells in relation to recurrence of carcinoma of the colon.
JAMA 154:1251-1254, 1954.
11. Keynes W: Implantation from the bowel lumen in
cancer of the large intestine. Ann Surg 153:357-64, 1961.
12. Norgren J, Svensson JO: Anal implantation
metastasis from carcinoma of the sigmoid colon and rec-
tum. Br J Surg 72:602, 1985.
13. Beahrs OH, Phillips JW, Dockerty MB: Implanta-
tion of tumor cells as a factor in recurrence of carcinoma
of the rectosigmoid. Cancer 8:831-838, 1955.
14. Boreham P: Implantation metastasis from cancer of
the large bowel. Br J Surg 48:103-108, 1958.
15. Le Quesne LP, Thomson AD: Implantation recur-
rence of carcinoma of rectum and colon. N Engl J Med
258:578-582, 1958.
16. Rollinson PD, Dundas S: Adenocarcinoma of the
sigmoid colon seeding into pre-existing fistula in ano. Br
J Surg 71:664-665, 1984.
17. Guiss RL: The implantation of cancer cells within
a fistula-in-ano. Surgery 36:136-139, 1954.
18. Personal communication: Drs. Salvati, Rubin, and
Eisenstat, Plainfield, NJ.
19. Malmberg M, Graffnes H, Ling L, Olsson S: Recur-
rence and survival after anterior resection of the rectum
using the end-to-end anastomotic stapler. Surg Gynecol
Obstet 163:231-234, 1986.
CASE REPORT
Colonic Lipomas
Endoscopic and Radiologic Characteristics
GEOBEL A. MARIN, MD
GABRIELE L. VILLA, MD
We present three cases of colonic lipomas; the first lipoma was removed
endoscopically, the other two lesions were left in situ following recognition
of their benign natures. We recommend that lesions of the colon recognized
as lipomas and found incidentally be left alone.
Gastrointestinal endoscopists recommend re-
moval of colonic polyps because of the con-
cern that polypoid lesions are malignant or
will become malignant. Should the probability of
malignancy be known with some degree of certainty,
lesions that have little or no potential for malignant
Figure 1. Descending colon in patient 1. There is smooth,
movable growth covered by Intact mucosa.
Drs. Marin and Villa are affiliated with the
Gastrointestinal Section and Radiology Department,
Mercer Medical Center, Trenton. Requests for reprints
may be addressed to Dr. Marin, Mercer Professional
Bldg., Suite 401, 416 Bellevue Avenue, Trenton, NJ
08618.
changes could be left alone, thus sparing the patient
a potentially dangerous procedure.
We encountered lipomas of the colon in three pa-
tients examined by radiologic and endoscopic tech-
niques. Although the first lesion was removed en-
doscopically, augmented evaluation of the two other
patients led to the recommendation that no removal
be carried out. The main reason for this report is to
illustrate the appearance of colonic lipomas and to
recommend, that once properly recognized, these
lesions be left alone.
Case Report 1. A 53-year-old diabetic woman was
Figure 2. Endoscopic appearance of a lipoma found in patient
2. It is smooth, soft to touch, and easily indented with the biopsy
forceps.
VOL. 87— NUMBER 4 APRIL 1990
301
CASE REPORT
found to have occult blood in her stools during the
course of a routine physical examination. She had
an antral ulcer in the past as well as diverticulosis.
A barium enema (Figure 1) revealed the presence of
the 13 mm lesion in the proximal descending colon;
it was movable and on a stalk. Colonoscopy con-
firmed its presence; it was removed and found to be
a submucosal lipoma without any malignant poten-
tial. A recurrent antral ulcer was found, probably
explaining occult blood in the stools.
Case Report 2. A 77-year-old female was referred
for an endoscopic evaluation, two years following
removal of an adenocarcinoma of her transverse
colon. Her entire colon appeared normal except for
a smooth, soft polypoid lesion (Figure 2) measuring
1 x 1.5 cm in her ascending colon. A barium enema
confirmed its presence and the smoothness of the
lesion suggested a lipoma. A computed tomography
(CT) scan of the abdomen (Figure 3) revealed a fat
density mass just above the ileocecal valve. A co-
lonoscopy carried out 12 months later again revealed
the presence of a smooth, unchanged polypoid lesion
(Figure 4). Because we felt she had a benign lipoma
of the ascending colon, the lesion was not removed.
Case Report 3. A 43-year-old woman underwent
a colonoscopy following resection of an adenocarci-
noma three years before. Her colon appeared nor-
mal, but a smooth, soft sessile tumor, measuring 1
x 1.5 cm, was found (Figure 5) in her ascending
colon. A barium enema confirmed its presence. A CT
scan of the abdomen showed the lesion to have fat
density. Since we were reasonably certain we were
dealing with a lipoma, the lesion was left intact. A
followup colonoscopy performed 18 months later re-
vealed a normal colon and no change of the previous-
ly diagnosed lipoma of the ascending colon.
METHOD
Colonoscopy was performed using an Olympus co-
lonoscope following standard bowel preparation. CT
Figure 3. CT scan of the abdomen on patient 2. There is a fat
density mass in the region of the ileocecal area.
scan of the abdomen was obtained using a
Somatome DRH scanner (Siemens, Iselin, New Jer-
sey), with scanning times of three or four seconds,
at 8 mm section thickness, and 8 mm table incre-
ments. Barium enema was performed following stan-
dard bowel preparation.
ENDOSCOPIC AND RADIOLOGIC FINDINGS
On endoscopy, the three polypoid lesions ap-
peared to be covered by a normal, smooth, and
Figure 4. Endoscopic appearance of an ascending colon lipoma
on patient 2. As in the two other cases, it is soft and smooth
and with a positive "pillow sign.”
Figure 5. Lipomatous lesion found in the ascending colon of
patient 3.
302
NEW JERSEY MEDICINE
CASE REPORT
glistening mucosa; biopsy forceps applied to the
lesions showed them to be soft and movable. The
closed biopsy forceps indented the lesions with ease.
The barium enemas showed comparable findings:
these lesions are smooth, compressible, and covered
by normal-looking mucosa. Some lesions may be
pedunculated, like the one removed on our first pa-
tient, but more frequently the stalk is short and
Table. Clinical, endoscopic, and radiologic characteristics of three patients with colonic
lipomas.
Colonoscopy Radiology
Patient
Sex
Age
Location
Size
(cm)
Mucosa
“Pillow
Sign"
Barium Enema
CT Scan
1
F
53
Descending colon
1.3
- 1.5
Normal
+
Smooth mass,
normal mucosa
Not Done
2
F
77
Ascending colon
1.0
x 1.5
Normal
+
Smooth mass,
normal mucosa
Fat Density
3
F
43
Ascending colon
1.0
x 1.5
Normal
+
Smooth mass,
normal mucosa
Fat Density
growths were smooth and covering mucosa looked
intact. CT scans in two cases proved the lesions to
have the density of fat.
The Table summarizes the report.
COMMENTS
Lipomas of the colon are uncommon, but rep-
resent the second most common benign colonic
tumor, second in frequency to the adenomatous
hyperplastic polyps.' Most lipomas are entirely
asymptomatic and found accidentally. Those
lipomas large enough to cause mechanical complica-
tions may lead to diverse symptoms such as vomit-
ing, palpable mass, or gastrointestinal bleeding.-' In-
tussusception and bowel obstruction also may occur
and would require surgical treatment.’
Colonoscopy and polypectomy now are considered
routine procedures. However, morbidity and mor-
tality may occur; transmural burns, bowel per-
forations, and even explosion of flammable gases
have been seen.1 2 3 4 Thus, morbidity may be avoided
should the endoscopist know with a reasonable
degree of certainty that the tumor found on a given
patient has no potential for malignancy and is caus-
ing no symptoms.
The endoscopic characteristics of colonic lipomas
are typical enough to make a preoperative diagnosis,
even in the absence of histological confirmation;
thick.5 Lesions can be indented easily with a closed
biopsy forceps, but on withdrawal of the forceps,
they rapidly recover their original shape, much like
a foam pillow;5 hence this has been called the
“pillow-sign.”
The radiologic appearances also are fairly typical.
Barium enema examinations showed smooth poly-
poid lesions, with sharp borders and configuration.
This may change during peristalsis. However, radio-
logical differentiation between lipomas and other
submucosal lesions may not be possible by a barium
enema alone.
Computed tomography has added a new
dimension to the recognition of polypoid lesions of
the gastrointestinal tract. Lipomas manifest a low
attenuation coefficient indicative of a fat density.
Farah and colleagues were able to distinguish
lipomas in the duodenum from other lesions in 2 of
14 patients who presented with duodenal
neoplasms.’ Thus, by using endoscopy, conventional
barium enemas, and CT scans, physicians may
diagnose colonic polyps as being, “most likely,
lipomatous in origin.” If there are no associated
complications (obstruction, intussusception, or
gastrointestinal bleeding), there is no reason to re-
move these lesions. ■
Submitted: October 1989;
Accepted: November 1989.
REFERENCES
1. Taylor BA, Wolf BS: Colonic lipomas: Report of two
unusual cases and review of the Mayo Clinic experience,
1976-1985. Dis Colon Red 30:888-893, 1987.
2. Hurwitz M, Redleaf P, Williams H, et al.: Lipomas
of the gastrointestinal tract: An analysis of 72 tumors. Am
J Roentgenol 99:84-89, 1967.
3. Fawaz K, Bloom S, Pappas C, et al.: Adult in-
tussusception presenting with transient intestinal
ischemia. Am J Roentgenol 73:265-270, 1980.
4. Tedesco FJ: Colonoscopy polypectomy: Complica-
tions, in, Therapeutic Gastrointestinal Endoscopy (First
Edition). New York, NY, Igaker-Shoin Medical Pub-
lishers, 1985, pp 284-286.
5. Wolf BS: Lipoma of the colon. JAMA 235:2225-2228,
1976.
6. Khanaja FI: Pedunculated lipoma of the colon: Risks
of endoscopic removal. Southern Med J 80:1170-1174,
1987.
7. Farah MC, Jafri SZH, Schwab RE, et al.: Duodenal
neoplasms: Role of CT. Radiology 162:839-843, 1987.
VOI R7 — NUMBER 4 APRIL 1990
303
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NEW JERSEY MEDICINE
Clinical
Decision Making
Conference on Therapeutic and Diagnostic Options
HOWARD HOLTZ, MD
LEONARD BIELORY, MD
NEIL FREUND, MD
NORMAN LASKER, MD
Clinical decision-making conference will be a new quarterly feature. Sugges-
tions or contributions should be addressed to the authors. The authors
discuss a 67-year-old male with coronary heart disease and renal failure.
Dr. Neil Freund (senior resident in internal medi-
cine): A 67-year-old male presented with acute
shortness of breath, chest pain, and hypotension. He
was diagnosed as having acute pulmonary edema
and underwent cardiac catheterization revealing
triple-vessel disease. He was transferred to UMDNJ.
Upon admission, the patient was asymptomatic.
There was a history of diabetes mellitus for 10 years
and longstanding hypertension. He smoked one pack
Dr. Holtz is affiliated with the Division of General Medi-
cine and Dr. Bielory is affiliated with the Division of Al-
lergy and Immunology, UMDNJ-New Jersey Medical
School. Requests for reprints may be addressed to Dr.
Holtz, UMDNJ-University Hospital, Room 1-246, 150
Bergen Street, Newark, NJ 07103-2757.
of cigarettes per day for many years. His medi-
cations on admission were chlorpropamide, nitro-
glycerin paste, diltiazem, furosemide, and docusate
sodium. Blood pressure was 150/90. There was a
right carotid bruit. Auscultation of the lungs was
normal; there was no jugular venous distention. A
left ventricular S4 gallop was heard. The abdomen
was nontender and without organomegaly. There
was no peripheral edema or skin rashes. A stool
specimen was negative for occult blood. Urea nitro-
gen was 43; creatinine was 2.4 mg/dl; glucose was
301 mg/dl; sodium was 135 mmol; potassium was 4.9
mmol; chloride was 93 mmol; carbon dioxide was 30
mmol; calcium was 10.5 mg/dl; phosphate was 6.0
mg/dl; and albumin was 3.9 gm/dl. The creatine
VOL. 87— NUMBER 4 APRIL 1990
305
CLINICAL DECISION MAKING
kinase was 1898 U and the MB fraction was 1.8
percent. Serum alanine aminotransferase was 31 U
and the aspartate aminotransferase was 42 U. Total
cholesterol was 276 mg/dl. White cell count was
11,900 with 9 percent eosinophils. The hematocrit
was 43.9 percent and the platelet count 257,000.
Prothrombin time and partial thromboplastin time
were not prolonged. The urine gave a + + + + for
glucose, a negative test for blood, and a trace
positive test for protein. There were 4 to 8 red cells
and 5 to 10 hyaline casts per high-power field. Urine
myoglobulin was negative. An electrocardiogram re-
vealed normal sinus rhythm, left ventricular hyper-
trophy, Q waves in leads II and III, and a-VF and
inverted T waves in leads V4-V6. An x-ray of the
chest revealed normal heart size and lung fields;
there was calcification in the aorta.
On hospital day 2, the patient experienced
bilateral calf tenderness. On hospital day 7, the
myalgias had progressed and the patient ex-
perienced abdominal pain, nausea, and vomiting. A
repeat creatine kinase was 1800 U (MB fraction 0.9
percent). An abdominal ultrasound was performed
and showed no abnormalities in the kidneys, liver,
gallbladder, and pancreas. An upper gastrointestinal
series was done and also was normal. On hospital
day 10, the urea nitrogen was 63 mg/dl and the
creatinine was 4.6 mg/dl. A 24-hour urine creatinine
clearance was 10 ml/min. The patient continued to
have persistent abdominal pain with nausea; the
stool examination remained negative for occult
blood. On hospital day 15, a livedo reticularis rash
appeared over the lower extremities. The peripheral
pulses were unchanged. A renal perfusion scan was
performed and showed decreased function and per-
T able. Differential diagnosis of skin
livedo reticularis.
Atheromatous embolism
Cryoimmunoglobulinemic syndrome
Lupus erythematosus systemic
Pheochromocytoma
Polyarteritis nodosa systemic
Rheumatoid arteritis
Vasculitis nonspecific allergic
Hypersensitivity vasculitis
Beriberi heart disease
Relapsing polychondritis
Wegener’s granulomatosis
fusion to both kidneys. The patient became anuric,
unresponsive to diuretics, and required hemodi-
alysis. On hospital day 16, the urea nitrogen was 101
mg/dl, and the creatinine was 7.8 mg/dl. A diag-
nostic procedure was performed.
Dr. Norman Lasker (director, Division of
Nephrology): The first consideration in approaching
an azotemic patient is to determine whether the
renal insufficiency is acute or chronic.1'2 This patient
had acute renal failure based on the following find-
ings: no previous history of renal disease, a normal
hemoglobin of 14.9 gm percent, and a progressive
downhill course of renal failure. A measure of kidney
size by kidney, ureter, bladder (KUB), or ultrasound
should be included to rule out small chronically
scarred kidneys.
Acute renal failure can be categorized as prerenal,
renal, and postrenal, or obstructive. This patient
could have had prerenal failure due to myocardial
damage and congestive heart failure, or dehydration
secondary to furosemide. However, there was no
clinical evidence of heart failure or dehydration and
the BUN/creatinine ratio was not increased.
Obstructive or postrenal failure due to prostatic
hypertrophy or bladder dysfunction must be con-
sidered in a 67-year-old diabetic man with acute
renal failure. These could be ruled out by bladder
palpation, a normal voiding pattern, and a small
postvoiding residual urine volume. It now has be-
come standard practice to perform a renal ultra-
sound in new patients with renal failure to de-
termine renal size and check for a dilated urinary
collecting system. The renal ultrasound in this case
was normal.
The elimination of the possibility of obstructive
renal disease and prerenal failure leaves us with a
patient with acute renal failure due to an intrarenal
disease. Intrarenal disease causing acute renal fail-
ure can be classified on the basis of the primary
anatomical structure involved. It should be under-
stood that more than one structure can be involved,
but usually the pathological change in a single
anatomic location characterizes the lesion. There are
four subdivisions for intrarenal acute renal failure:
vascular, glomerular, tubular, and interstitial.
The vascular lesions include embolization or
thrombosis of the intrarenal extraglomerular vessels;
the glomerular lesions mainly are inflammatory
lesions of the glomerular capillaries causing rapidly
progressive glomerulonephritis; the tubular lesions
include acute tubular necrosis and blockage of the
tubules by proteins or urates and the interstitial
disease is ^icute interstitial nephritis, an allergic re-
action to drugs such as methicillin.
In the present case, bilateral renal vascular em-
bolization could have originated from a cardiac
mural thrombus secondary to a recent myocardial
306
NEW JERSEY MEDICINE
CLINICAL DECISION MAKING
infarction. Since cardiac emboli are large enough to
occlude larger intrarenal vessels, they result in areas
of infarction which frequently are associated with
costovertebral angle pain, microscopic hematuria,
and hypertension. A high lactic dehydrogenase
(LDH) and relatively normal serum glutamic ox-
aloacetic transaminase (SGOT) is characteristic of
this type of renal embolization, but no LDH was
available in this case. The patient did not have cos-
tovertebral angle pain or hypertension. Another type
of embolic vascular disease which can cause acute
renal failure is atheroembolic renal disease in which
a severely atheromatous aorta sheds small emboli to
the kidney and other organs. Macroscopic poly-
arteritis produces narrowing or occlusion of the me-
dium-sized renal vessels, but usually does not
produce acute renal failure. Hypertension occurs in
over 50 percent of the cases and neurological involve-
ment— mononeuritis multiplex — is common. Other
vascular lesions which can produce acute renal fail-
ure include malignant hypertension with malignant
arteriolarnephrosclerosis and hemolytic-uremic syn-
drome (HUS). The latter includes thrombotic-
thrombocytopenic purpura (TTP) and hemolytic-
uremic syndrome of children and adults. HUS is
characterized by the intravascular deposition of
platelets and fibrin, a microangiopathic hemolytic
anemia (schistocyte or helmet cells in peripheral
blood) and thrombocytopenia. The present patient
was not anemic and had no evidence of throm-
bocytopenia such as purpura.
Glomerular lesions producing rapidly progressive
glomerulonephritis are associated with acute renal
failure. The pathological lesion is crescentic
glomerulonephritis which can be seen in severe cases
of postinfectious glomerulonephritis, membrano-
proliferative glomerulonephritis, Goodpasture’s syn-
drome, microscopic polyarteritis, Wegener’s granu-
lomatosis, lupus nephritis, Henoch-Schonlein
purpura, and cryoglobulinemia. Rapidly progressive
glomerulonephritis can be eliminated from consider-
ation in this patient because of the low degree of
proteinuria and the absence of red blood cell casts
in the urine.
Tubular lesions including acute tubular necrosis
and/or tubular obstruction must be considered in
this setting. The renal failure followed a coronary
arteriogram suggesting the possibility of contrast
dye acute renal failure. Contrast dye-associated
renal failure is one type of acute tubular necrosis.
It follows intravenous or intra-arterial use of radio-
opaque dyes. The patients most likely to develop
significant acute renal failure after radiocontrast
dyes have pre-existing renal failure. Occasionally, an
allergic reaction to the dye can be associated with
acute renal failure. Increasing azotemia usually is
noted one or two days after the administration of the
dye, accompanied by a decrease in urine output.
Renal failure typically lasts for two to five days with
recovery by day seven (bell-shaped curve), and it is
uncommon for these patients to require long-term
dialysis. The urine sediment shows tubular cell casts
and muddy brown coarsely granular casts which are
characteristic of acute tubular necrosis.
This patient did not follow the typical “bell-
shaped curve” course of nephropathy since his
azotemia progressed slowly and continuously over a
15-day period and then reached an elevated level
plateau. The patient had no acute allergic mani-
festations at the time of the administration of the
dye, suggesting other causes for the eosinophilia.
The benign urine sediment, and the course of the
renal failure indicate that radiocontrast dye
nephropathy is unlikely in this patient.
Acute tubular necrosis secondary to hypotension
preceding the patient’s admission to the referring
hospital also is unlikely because of the lack of uri-
nary findings, i.e. trace protein with no muddy
brown granular casts. The delayed onset of renal
failure one week after the hypotensive episode and
its prolonged course are not characteristic of acute
tubular necrosis.
Rhabdomyolysis can cause acute renal failure due
to blockage of the tubules by myoglobin and the
tubular toxicity of this muscle protein. Myoglobin
is released from the muscle secondary to prolonged
coma and muscle compression as seen in narcotic or
drug overdosage. It also can be caused by alco-
holism, seizures, strenuous exercise, severe viral in-
fections and occasionally severe hypophosphatemia,
hypokalemia, or McArdle’s syndrome. It should be
suspected if the urine dip stick tests strongly positive
for blood but the sediment shows only a few red
blood cells/HPF. The muscle damage results in a
high creatinine phosphokinase (CPK), serum
glutamic oxaloacetic transaminase (SGOT), phos-
phorus, potassium, creatinine, and uric acid. (Ex-
pect a high serum creatinine-BUN ratio.) Serum
calcium is low in the early stages because of calcium
uptake by the damaged muscles and the increased
phosphorus level. Although the patient had a high
CPK and elevated phosphorus, the urine tested
negative for myoglobin and the serum potassium,
calcium, and creatinine-BUN ratio were normal.
Acute interstitial nephritis (AIN) usually is a hy-
persensitivity reaction to drugs such as methicillin,
penicillins, sulfa drugs, nonsteroidal anti-inflam-
matory drugs, rifampin, cimetidine, phenytoin, al-
lopurinol, and many other agents. The interstitial
inflammation mainly involves lymphocytes and
monocytes, but includes eosinophils, neutrophils,
and basophils. It leads to a decreased glomerular
filtration rate due to the interstitial edema and
vascular compression and also can cause secondary
VOL. 87-NUMBER 4 APRIL 1990
307
CLINICAL DECISION MAKING
tubular damage. The patient may present with the
full-blown manifestations of a hypersensitivity reac-
tion including fever, a maculopapular rash, pe-
insufficiency remains permanently, although an oc-
casional case will improve with time. The long-term
prognosis is poor because of the severe atheromatous
This case was presented in a weekly House Officer Clinical Decision-Making
Conference. The residents are taught to use techniques that make the de-
cision process more explicit and rational. The case under discussion was
a differential diagnostic problem that lent itself to an analysis by an artificial
intelligence program called Quick Medical Reference. A microcomputer in-
stalled with QMR was brought to the conference.
ripheral eosinophilia, arthralgias, and eosinophilur-
ia, but frequently the latter is the only diagnostic
finding. Although the patient had eosinophilia, no
eosinophils or white blood cells were noted in the
urine. Furosemide which is a sulfonamide derivative
is an infrequent cause of AIN.
The occurrence of renal failure soon after the pass-
age of an arterial catheter into the coronary ostia of
a diabetic man with atherosclerotic disease and the
admission findings of eosinophilia and an elevated
CPK with scarce urinary findings should suggest
atheroembolic renal disease.49 This is associated
with severe aortic atheromatous disease and usually
occurs following manipulation of the aorta, although
it can occur spontaneously. The emboli represent
atheromatous hyaline material containing choles-
terol crystals. They lodge in small arteries in the
kidney, pancreas, spleen, lower extremity muscles,
toes, and the retinal vessels. In the latter, they
produce bright orange Hollenhorst bodies."1 The dis-
solved cholesterol crystals resemble bi-concave par-
allel slits after fixation. These emboli occlude
smaller vessels than do the nonatheromatous emboli
so that the involved organs can remain viable, i.e.
they produce organ ischemia and fibrosis and not
infarction. Therefore, unlike nonatheromatous em-
bolic renal disease, there may be no CVA pain and
no hypertension.
The exposure of the atheroembolus to the circula-
tion can result in an immunological reaction as-
sociated with eosinophilia and hypocomplemente-
mia, and the urinalysis may be relatively normal.
Livedo reticularis, as seen in this patient, is a bluish,
lacy discoloration of the skin due to occlusion of the
small arterioles and dilation of the capillaries and
venules with desaturated blood." The patient’s ab-
dominal pain and myalgias may have been due to
pancreatic and muscle involvement. The course of
the acute renal failure is progressive, reaching a
plateau in five to ten days. In most cases, renal
disease present in these patients. The diagnosis may
be confirmed by finding the typical atheroemboli in
biopsied muscle, skin, or kidney.12 The kidney
biopsy should be an open one since the vascular
involvement is irregular and may be missed in a
small specimen.
The presentation and clinical findings in this pa-
tient are most compatible with the diagnosis of
atheroembolic renal disease.
Dr. Howard Holtz: This case was presented in
our weekly House Officer Clinical Decision-Making
Conference. The residents are taught to use tech-
niques that make the decision process more explicit
and rational.13 16 The case under discussion was a
differential diagnostic problem that lent itself to
analysis by an artificial intelligence program called
Quick Medical Reference (QMR). A microcomputer
installed with QMR was brought to the conference.
In 1972, Myers, Pople, Miller, and coworkers at
the University of Pittsburgh set out to develop a
computer program which could simulate the role of
an expert consultant in internal medicine. This for-
midable undertaking became the INTERNIST-1
program.17 An evaluation of the program using cases
from clinicopathologic conferences, showed IN-
TERNIST-1 had comparable diagnostic acumen to
the attending physicians at a major teaching hospi-
tal. However, the program’s diagnostic accuracy was
not as good as the invited expert clinician.17 QUICK
MEDICAL REFERENCE (QMR) is the successor to
INTERNIST-1.'8 Modifications include an emphasis
on manipulating the rich knowledge base for educa-
tional purposes and use as a diagnostic aid rather
than a definitive diagnostic consultant.
The diagnostic algorithms of QMR are based on
a well-studied model of the clinical reasoning pro-
cess;19'20 however, there are some aspects of differen-
tial diagnosis QMR cannot emulate. For example,
in this case, Dr. Lasker used the clinical course to
rule out radiocontrast dye nephropathy by observing
308
NE^JERSE^MEDICINE
CLINICAL DECISION MAKING
the patient’s azotemia did not follow a bell-shaped
curve after the dye exposure. QMR cannot yet easily
use the temporal sequence of clinical observations in
its differential diagnosis. In addition, pathophysio-
logical states such as prerenal azotemia are difficult
to integrate into the program without considering
them disease entities (Table).
If there are some pitfalls in exactly capturing the
human cognitive process of diagnosis, all is forgiven
when one observes the program’s capacity for teach-
ing. This is best illustrated by participants who
asked to use QMR at the end of the conference.
A third-year medical student wanted to know why
systemic lupus erythematosus was not chosen as a
diagnostic hypothesis. QMR provided the student
with a list of the patient’s findings that supported
the diagnosis of lupus and a longer list of case find-
ings that were not consistent with lupus. It
prompted the student with questions such as “ANA
positive?” which would be useful in making the
diagnosis. Similarly, a resident wanted to know
other diseases associated with the rash livedo re-
ticularis. A printout of the ten diseases in QMR’s
knowledge associated with the rash was produced.
On a more advanced level, an attending physician
wanted to know case findings that were common
to polyarteritis nodosa and atheromatous embolism
since she had considered both in her differential
diagnosis. QMR quickly provided her with a list of
findings common to both diseases, such as calf mus-
cle tenderness, and gave her the option of having a
list of findings which were unique to each disease.
She decided to pick several clinical “pearls” to com-
mit to memory to help differentiate these diseases
in the future.
The case findings were entered into QMR in 15
minutes, before the conference began. The case
analysis took seconds and was done after Dr. Lasker
discussed his diagnostic impressions. The readout
was: “Potentially Interesting Diagnostic Hypothe-
ses: Atheromatous Embolism, Myocardial Infarction
Acute.” In this case, the leading diagnosis concurred
with Dr. Lasker’s assessment and a second
hypothesis was offered.
Dr. Neil Freund: The diagnostic procedure was
a muscle biopsy of the left posterior calf which re-
vealed cholesterol emboli in the skeletal muscle ar-
terioles, diagnostic of atheroembolic disease.
As there is no specific treatment for this disorder,
the patient’s care was supportive, including tempo-
rary hemodialysis. He began to urinate. Abdominal,
dermatologic, and muscle findings resolved and he
was discharged. Six weeks later, he was readmitted
with chest pain, severe renal failure, lower extremity
ulcerations, and cyanosis. He expired shortly after
admission. An autopsy revealed atherosclerosis in
the ascending aorta, recent myocardial infarction,
and fatty change in the liver. In addition, atheroem-
boli were found in the splenic artery, with splenic
infarction, and the renal arterioles. ■
Submitted: May 1989; Accepted August 1989
REFERENCES
1. Lasker N: The diagnosis and treatment of renal in-
sufficiency. J Med Soc NJ 63:545, 1966.
2. Burke JF Jr, Lasker N: Acute renal failure in the
surgical patient, in Practice of Surgery. Hagerstown, MD,
Harper and Row Publishers, chapter 17, 1977.
3. Retan JW, Miller RW: Microembolic complications
of atherosclerosis: Literature review and report of a pa-
tient. Arch Intern Med 118:534, 1966.
4. Richards AM, Eliot RS, Kanjuh VI, et al.:
Cholesterol embolism: A multiple-system disease mas-
querading as polyarteritis nodosa. Am J Cardiol
15:696-707, 1965.
5. Kassirer JP: Atheroembolic renal disease. N Engl J
Med 280:812-818, 1969.
6. Rosansky SJ, Deschamps EG: Multiple cholesterol
emboli syndrome after angiography. Am J Med Sci
288:45-48, 1984.
7. Drost H, Buis B, Hahn D, et al.: Cholesterol em-
bolism as a complication of left heart catheterization:
Report of seven cases. Br Heart J 52:339-342, 1984.
8. Case Records of the Massachusetts General Hospital
Case 30—1986. N Engl J Med 315:308, 1986.
9. Fine MJ, Kapoor W, Falanga V: Cholesterol crystal
embolization: A review of 221 cases in the English litera-
ture. Angiology 38:769, 1987.
10. Hollenhorst RW: Significance of bright plaques in
the retinal arterioles. JAMA 178:23, 1961.
11. Kalter DC, Randolph A, McGavran M: Livedo re-
ticularis due to multiple cholesterol emboli. J Am Acad
Dermatol 13:235, 1985.
12. Anderson WR: Necrotizing angiitis associated with
embolization of cholesterol: Case report with emphasis on
the use of muscle biopsy as a diagnostic aid. Am J Clin
Pathol 43:55-71, 1965.
13. Sox HC: Probability theory in the use of diagnostic
tests: An introduction to critical study of the literature.
Ann Intern Med 104:60-66, 1986.
14. Paulker SG, Kassirer JP: Decision analysis. N Engl
J Med 316:250-258, 1987.
15. Shortliffe EH: Computer programs to support
clinical decision-making. JAMA 258:61-66, 1987.
16. Sackett DL, Haynes RB, Tugwell P: Clinical
Epidemiology. Boston, MA, Little, Brown, 1985.
17. Miller RA, Pople HE, Myers JD: INTERNIST-1, an
experimental computer-based diagnostic consultant for
general internal medicine. N Engl J Med 307:468-476,
1982.
18. Miller RA, McNeil MA, Challinor SM, et al.: The
INTERNIST- 1/QUICK MEDICAL REFERENCE proj-
ect— status report. West J Med 145:816-822, 1986.
19. Barrows HS, Feltovich PJ: The clinical reasoning
process. Med Educ 145:816-822, 1986.
20. Shortliffe EH: Reasoning methods in medical con-
sultation systems: Artificial intelligence approaches.
Comput Biomed 18:5-14, 1984.
VOL. 87 NUMBER 4 APRIL 1990
309
Because safety
cannot be taken for granted
in H2-antagonist therapy
Minimal potential for
drug interactions
Unlike cimetidine and ranitidine ,7
Ax/d does not inhibit the cytochrome
P-450 metabolizing enzyme system.2
Swift and effective
H2-antagonist therapy
■ Most patients experience
pain relief with the first dose3
■ Heals duodenal ulcer
rapidly and effectively4 5
■ Dosage for adults with active
duodenal ulcer is 300 mg once nightly
(150 mg b.i.d. is also available)
References
1 . USP PI Update. September/ October 1988. p 120.
2 Br J Clin Pharmacol 1985:20:710-713.
3. Data on file. Lilly Research Laboratories.
4. Scand J Gastroenterol 1987:22(suppl 136) 61-70.
5. Am J Gastroenterol 1989:84:769-774
AXID®
nizatidine capsules
Brief Summary. Consult the package literature for complete
information.
Indications and Usage: t. Active duodenal ulcer- for up to eight weeks
of treatment Most patients heal within four weeks.
2. Maintenance therapy -for healed duodenal ulcer patients at a
reduced dosage of 1 50 mg h.s. The consequences of therapy with Axid
for longer than one year are not known.
Contraindication: Known hypersensitivity to the drug. Use with caution
in patients with hypersensitivity to other H2-receptor antagonists.
Precautions: General- 1. Symptomatic response to nizatidine therapy
does not preclude the presence of gastric malignancy.
2. Dosage should be reduced in patients with moderate to severe
renal insufficiency.
3. In patients with normal renal function and uncomplicated hepatic
dysfunction, the disposition of nizatidine is similar to that in normal
subjects.
Laboratory 7es/s -False-positive tests for urobilinogen with Multistix*
may occur during therapy.
Drug Interactions -No interactions have been observed with theophyl-
line, chlordiazepoxide, lorazepam, lidocaine, phenytoin, and warfarin. Axid
does not inhibit the cytochrome P-450 enzyme system; therefore, drug
interactions mediated by inhibition of hepatic metabolism are not expected
to occur. In patients given very high doses (3,900 mg) of aspirin daily,
increased serum salicylate levels were seen when nizatidine, 150 mg
b.i.d., was administered concurrently.
Carcinogenesis. Mutagenesis, Impairment ol Fertility -A two-year oral
carcinogenicity study in rats with doses as high as 500 mg/kg/day
(about 80 times the recommended daily therapeutic dose) showed no
evidence ot a carcinogenic effect. There was a dose-related increase in
the density of enterochromaffm-like (ECL) cells in the gastric oxyntic
mucosa. In a two-year study in mice, there was no evidence of a
carcinogenic effect in male mice, although hyperplastic nodules ol the
liver were increased in the high-dose males as compared with placebo.
Female mice given the high dose ot Axid (2,000 mg/kg/day, about 330
times the human dose) showed marginally statistically significant
increases in hepatic carcinoma and hepatic nodular hyperplasia with no
numerical increase seen in any of the other dose groups. The rate of
hepatic carcinoma in the high-dose animals was within the historical
control limits seen for the strain of mice used. The female mice were
given a dose larger than the maximum tolerated dose, as indicated
by excessive (30%) weight decrement as compared with concurrent
controls and evidence of mild liver injury (transaminase elevations). The
occurrence of a marginal finding at high dose only in animals given
Axid* (nizatidine, Lilly)
an excessive and somewhat hepatotoxic dose, with no evidence of a
carcinogenic effect in rats, male mice, and female mice (given up to
360 mg/kg/day, about 60 times the human dose), and a negative
mutagenicity battery are not considered evidence of a carcinogenic
potential for Axid.
Axid was not mutagenic in a battery ot tests performed to evaluate its
potential genetic toxicity, including bacterial mutation tests, unscheduled
DNA synthesis, sister chromatid exchange, mouse lymphoma assay,
chromosome aberration tests, and a micronucleus test
In a two-generation, perinatal and postnatal fertility study in rats, doses
of nizatidine up to 650 mg/kg/day produced no adverse effects on the
reproductive performance of parental animals or their progeny.
Pregnancy-Teratogenic Effects- Pregnancy Category C-Oral repro-
duction studies in rats at doses up to 300 times the human dose and in
Dutch Belted rabbits at doses up to 55 times the human dose revealed
no evidence of impaired fertility or teratogenic effect; but, at a dose
equivalent to 300 times the human dose, treated rabbits had abortions,
decreased number of live fetuses, and depressed fetal weights. On intra-
venous administration to pregnant New Zealand White rabbits, nizatidine
at 20 mg/kg produced cardiac enlargement coarctation ot the aortic
arch, and cutaneous edema in one fetus, and at 50 mg/kg, it produced
ventricular anomaly, distended abdomen, spina bifida, hydrocephaly,
and enlarged heart in one fetus. There are, however, no adequate and
well-controlled studies in pregnant women. It is also not known whether
nizatidine can cause fetal harm when administered to a pregnant woman
or can affect reproduction capacity. Nizatidine should be used during
pregnancy only if the potential benefit justifies the potential risk to
the fetus.
Nursing Mothers -Studies in lactating women have shown that
0.1% of an oral dose is secreted in human milk in proportion to plasma
concentrations. Because of growth depression in pups reared by treated
lactating rats, a decision should be made whether to discontinue nursing
or the drug, taking into account the importance of the drug to the mother.
Pediatric C/se — Safety and effectiveness in children have not been
established.
Use in Elderly ftf/e/rfs- Healing rates in elderly patients were similar
to those in younger age groups as were the rates of adverse events and
laboratory test abnormalities. Age alone may not be an important factor
in the disposition of nizatidine. Elderly patients may have reduced
renal function.
Adverse Reactions: Clinical trials ot varying durations included almost
5,000 patients. Among the more common adverse events in domestic
placebo-controlled trials of over 1,900 nizatidine patients and over 1,300
on placebo, sweating (1% vs 0.2%), urticaria (0.5% vs <0.01%), and
somnolence (2.4% vs 1.3%) were significantly more common with
nizatidine. It was not possible to determine whether a variety ol less
common events was due to the drug.
Axid* (nizatidine, Lilly)
Hepatic- Hepatocellular injury (elevated liver enzyme tests or alkaline
phosphatase) possibly or probably related to nizatidine occurred in some
patients. In some cases, there was marked elevation (>500 IU/L) in SGOT
or SGPT and, in a single instance, SGPT was >2,000 IU/L. The incidence
of elevated liver enzymes overall and elevations of up to three times
the upper limit of normal, however, did not significantly differ from that
in placebo patients. Hepatitis and jaundice have been reported. All
abnormalities were reversible after discontinuation of Axid
Cardiovascular- In clinical pharmacology studies, short episodes
ol asymptomatic ventricular tachycardia occurred in two individuals
administered Axid and in three untreated subjects.
CNS- Rare cases ot reversible mental confusion have been reported.
fntfocnne-Clinical pharmacology studies and controlled clinical trials
showed no evidence of antiandrogenic activity due to nizatidine.
Impotence and decreased libido were reported with equal frequency by
patients on nizatidine and those on placebo. Gynecomastia has been
reported rarely.
Hematologic- Fatal thrombocytopenia was reported in a patient
treated with nizatidine and another H2-receptor antagonist This patient
had previously experienced thrombocytopenia while taking other drugs.
Rare cases of thrombocytopenic purpura have been reported.
Integumental -Sweating and urticaria were reported significantly
more frequently in nizatidine- than in placebo-treated patients. Rash and
exfoliative dermatitis were also reported.
Hypersensitivity -As with other Hrreceptor antagonists, rare cases of
anaphylaxis following nizatidine administration have been reported.
Because cross-sensitivity among this class has been observed, H2-receptor
antagonists should not be administered to those with a history ot hyper-
sensitivity to these agents. Rare episodes of hypersensitivity reactions
(eg, bronchospasm, laryngeal edema, rash, and eosinophilia) have been
reported.
Order- Hyperuricemia unassociated with gout or nephrolithiasis was
reported. Eosinophilia, fever, and nausea related to nizatidine have been
reported.
Overtfosage: Overdoses ot Axid have been reported rarely. If overdosage
occurs, activated charcoal, emesis, or lavage should be considered along
with clinical monitoring and supportive therapy. Renal dialysis for four
to six hours increased plasma clearance by approximately 84%.
PV 2098 AMP 1091289]
Additional information available to the profession on request.
* Eli Lilly and Company
Indianapolis, Indiana
^ 46285
NZ-2924-B-04931 0 ©1990, ELI LILLY AND COMPANY
Axid® (nizatidine, Lilly)
310
NFW JERSEY MEDICINE -
Hazards Smokers
Impose
K.H. GINZEL, MD
Tobacco smoke is the single most important source of exposure for the
nonsmoking population to harmful air pollution. Uptake, biological reaction,
and associated pathology document the potential for serious health conse-
quences, raise ethical and legal questions, and demand comprehensive
legislative action.
If future generations were to tell the grim myth-
ology of the 20th century, they might allegorize
cigarette smoking as a two-headed, poison-
spewing hydra. The noxious emanation issuing from
one head would be the “mainstream” smoke inhaled
by the smoker and responsible for a death toll in the
United States alone that exceeds the number of
Americans killed in battle or who died of war-related
diseases in all wars ever fought by this nation. The
toxic effluent exuding from the other head of the
formidable monster would symbolize the smoke dis-
Dr. Ginzel is affiliated with the University of Arkansas for
Medical Sciences. Requests for reprints may be ad-
dressed to Dr. Ginzel, Department of Pharmacology and
Toxicology, University of Arkansas for Medical Sciences,
4301 West Markham Street, Mail Slot 611, Little Rock,
AR 72205.
charged into the indoor environment between the
puffs taken by the active smoker, designated “side-
stream” or “secondhand” smoke which amounts na-
tionally each year to an estimated 2.25 million
metric tons of gaseous and inhalable particulate
matter.2 Cigarette smoking is unique among the uses
and abuses of dependence-producing substances in
that it forces the casual bystander to participate in
the drug-taking act, because about two-thirds of the
total smoke of each cigarette is sidestream smoke.
Having to breathe smoke-polluted air is aptly called
“involuntary” smoking, a term more accurate than
the alternative designation of “passive” smoking.
The analogy of the two-headed snake could be
taken one step further. The victorious advance of the
cigarette in the last 70 years has spread two types
of pollution around the globe: the physical pollution
VOL. 87— NUMBER 4 APRIL 1990
311
of the smokers’ lungs and of indoor air spaces across
most nations, ultimately finding its way into the
nonsmokers’ body tissues, and the psychological pol-
lution by public channels of communication with
insidious deceptive messages.3
Society’s reaction to involuntary smoking, as in-
deed to smoking itself during the past four decades,
is characterized by a paradox where apathy and
complacency, inaction or insufficient action, lack of
governmental concern and regulation, altogether a
sort of “business as usual” attitude, are pitted
against the mounting evidence of harm and injury
and the few determined advocates struggling for
change.4
In this brief overview, I first address the various
health aspects of involuntary smoking, specifically
focusing on the predicament of the fetus and child;
secondly, I consider the ethical and legal implica-
tions; and thirdly, I ask what can and should be done
by informed citizens on behalf of the nonsmoking
public.
HEALTH ASPECTS OF INVOLUNTARY SMOKING
Only in the last 15 years have reports about the
consequences of tobacco smoke exposure of
nonsmokers increased from a trickle to a flood, cul-
minating in two recent landmark publications, one
by the National Academy of Sciences,'3 and the other
by the Surgeon General.6 Despite attempts of the
Tobacco Institute, the lobbying arm of the industry,
to denigrate the latter while in part approving the
former, the two reports came to identical con-
clusions: 1) Involuntary smoking is a cause of dis-
ease, including lung cancer, in healthy nonsmokers.
2) Children exposed to smoking in the home suffer
an increased frequency of respiratory infections and
delayed maturation of lung function. 3) En-
vironmental tobacco smoke is the dominant con-
tributor to indoor levels of respirable suspended par-
ticulates, and simple separation of smokers and
nonsmokers within the same airspace may reduce,
but does not eliminate, the exposure of the
nonsmoker to environmental tobacco smoke.
Tobacco smoke is not only the dominant indoor
air contaminant, but indoor air pollution, largely
because of tobacco smoke, consistently exceeds out-
door pollution.7" This discovery surprised those who
believed that outdoor levels would determine indoor
levels and that cleaning city air would protect
human health from the ravages of air pollution.
Huge sums of money have been spent to comply with
the National Ambient Air Quality Standards, estab-
lished by the Clean Air Act of 1970, which tacitly
were applied to the outdoors, totally ignoring the
indoor environment as one in its own right, and
where Americans spend about 90 percent of their
time.78
Environmental tobacco smoke. The major source
of environmental tobacco smoke is sidestream
smoke, for an active smoker retains 90 percent or
more of the inhaled mainstream smoke in his
body.56 Ambient air monitoring has supplied us with
detailed information on both mainstream smoke and
sidestream smoke. It is important to realize that
essentially the same major poisons and carcinogens
are present in sidestream smoke (and environmental
tobacco smoke) as in mainstream smoke inhaled by
the smoker. Moreover, their concentrations gener-
ally are much higher in sidestream than in main-
stream smoke and the sidestream/mainstream
smoke ratio has increased progressively as the
cigarette has evolved from the classical nonfilter
type to the modern cigarette with more efficient
filtertips and correspondingly lower tar yields for the
smoker.56 While the smoker is receiving less poison
in the mainstream smoke of modern cigarettes, the
nonsmoker actually may be getting more, due to the
fact that the total smoke yield (mainstream plus
sidestream smoke) of cigarettes with different main-
stream tar ratings (regular or ultra-light) remains
essentially the same.9
Environmental tobacco smoke can reach uncom-
fortably high concentrations in a variety of enclosed
and poorly ventilated air spaces, such as cars, of-
fices, and restaurants. Thus, it has been estimated
that a nonsmoker spending only one hour in a
smoke-filled bar may be exposed to as much
dimethylnitrosamine, a very potent carcinogen, as if
he actually had smoked 17 to 35 filtertip cigarettes.10
During an eight-hour work shift, a nonsmoking bar-
tender might breathe as much carbon monoxide and
benzo(a)pyrene, as if he himself had smoked about
36 cigarettes, provided he worked in a poorly ven-
tilated bar, or 12 cigarettes if the room air was
exchanged three times in every hour.11 Even at a
public arena, the exposure of nonsmokers to
benzo(a)pyrene during a two-hour period was esti-
mated to be equivalent to smoking 8 cigarettes.12
These astoundinglv high exposure estimates for
some smoke ingredients reflect their increased con-
centrations in sidestream as compared to main-
stream smoke. While they highlight the predicament
nonsmokers experience under somewhat extreme
conditions, they apply equally to smokers, who
usually take the lion’s share of the sidestream smoke
from their cigarettes.
Most of the carcinogens in tobacco smoke are con-
tained in the particulates, whose indoor levels have
been found to be alarmingly high. If radon gas
(trapped in enclosed air spaces in various parts of
the country) also is present, it is attracted by smoke
particulates and is kept afloat in the air in higher
concentrations and for longer periods than in the
absence of tobacco smoke.13 As a consequence, the
312
NEW JERSEY MEDICINE
exposure of the occupants to the radioactive gas
increases whenever cigarettes are smoked. Cigarette
smoke itself contains radionuclides with sidestream
smoke concentrations four times greater than those
in mainstream smoke. While a 1.5 pack-a-day
smoker may receive an annual dose of 8,000 milli-
rem,14 “the cumulative effects of repeated exposure
to large concentrations of secondhand smoke could
result in nonsmokers’ exposure exceeding the gov-
oxygen-carrying capacity of the blood.20 The latter
effect may be especially debilitating in patients with
compromised cardiovascular or pulmonary function.
But even healthy individuals exposed to carbon
monoxide concentrations of 30 parts per million and
above, caused by smoking in confined spaces, reach
carboxyhemoglobin levels at which visual dis-
criminative and psychomotor function begin to be
impaired.21,22
We must raise awareness through education in an area where craftily engineered illusion,
deception, and ignorance have worked hand-in-hand with our natural inclination toward
indifference and apathy. It is not easy to accept that what has been viewed as right and
normal, is wrong, abnormal, and requires remedial action.
ernment-recommended maximum dosage” of 500
millirem.15
Uptake and biological reaction. Estimates of ex-
posure of nonsmokers to environmental tobacco
smoke and its quantification expressed as cigarette
equivalents must be made separately for each agent,
for sidestream/mainstream smoke ratios differ.
Moreover, because of dilution and aging of side-
stream smoke, smoking frequency, room size, ven-
tilation, furnishings, and other factors, such calcu-
lations yield a rather wide range of results.6 What
ultimately matter are the extent of incorporation of
the various chemicals into the body and the
biological reactions they engender. There is ample
evidence that tobacco smoke components enter the
body of the nonsmoker. Nicotine and its metabolite,
cotinine, have been detected in the blood, urine, and
saliva of large numbers of nonsmokers, providing the
most specific, incontrovertible proof that passive ex-
posure to tobacco smoke does indeed lead to absorp-
tion of smoke constituents, for tobacco is the only
source of nicotine.5,6 Preliminary evidence also sug-
gests that passive smoking causes increased urinary
mutagenic activity which reflects carcinogen ex-
posure.5,6 Tests to reveal the reaction of carcinogens
with DNA, the initiating event in carcinogenesis,
already have produced positive results in smokers
and now are being extended to screen exposed
nonsmokers.16
Nicotine causes immediate effects which can be
demonstrated in both the active and the passive
smoker, the difference being only one of intensity.
In brief, nicotine increases the heart rate, particu-
larly in children,17 constricts blood vessels mani-
fested in a lowering of heat output, e.g. from the
hands,18 and dislodges cells lining the blood vessels.19
Acute impairment of exercise performance observed
during environmental tobacco smoke exposure was
attributable directly to the uptake and binding of
carbon monoxide to hemoglobin which reduces the
Most other acute effects of environmental tobacco
smoke involve irritation of the delicate tissues of
eyes and airways, resulting in itching, tearing, sneez-
ing, wheezing, coughing, sore throat, hoarseness,
headache, dizziness, and nausea, which entirely in-
capacitate about 3 percent of the total population,
people with hypersensitivity to ambient tobacco
smoke.7,8
Unquestionably, the most serious consequence of
chronic tobacco smoke exposure is lung cancer, esti-
mated to claim from 2,500 to 8,400 deaths annually
in the United States.5,6,23 The second major effect of
chronic exposure to tobacco smoke is the signifi-
cantly elevated incidence of respiratory illness and
middle-ear infections in small children.5,6,23 It truly
is appalling that infants too often are exposed to
tobacco smoke and may have more than ten times
the amounts of nicotine and cotinine in their urine
and saliva than “unexposed” controls24 who, as with
most people today, are not entirely free of nicotine
either.23,26
Pre- and postnatal involuntary smoking. The fetus
is an involuntary smoker receiving tobacco poisons
via the blood stream, whether the mother smokes
actively or passively. This truly is the ultimate in
involuntary smoking. With a smoking mother, a
well-defined “fetal tobacco syndrome” has been de-
scribed, consisting of growth retardation, increased
incidence of spontaneous abortions, miscarriages,
perinatal mortality, sudden infant deaths, and im-
pairment of emotional and cognitive development,
claiming some 4,000 infant lives each year.26 The
most consistent effect of maternal smoking is a re-
duction in birth weight; two-thirds of this reduction
occurs even in children born to environmentally
tobacco smoke-exposed mothers.27 Nicotine passes
into the fetal circulation and its major metabolite
has been identified in the amniotic fluid of both
actively and passively smoking mothers.28 Both nic-
otine and carbon monoxide can compromise the ox-
VOL. 87— NUMBER 4 APRIL 1990
313
ygen supply to the developing fetus. Cigarette smok-
ing is not only the “most powerful determinant of
poor fetal growth in the developed world,”26 but it
also reduces the normal height of children.29 Low
birthweight spells trouble for the health of the baby
for at least the first year of life, with more frequent
episodes of respiratory ailments and hospital ad-
missions.
Transplacental or early childhood exposure may
even increase the risk of cancer in adulthood.’0
Benzene in tobacco smoke increases the risk of
leukemia in children almost twofold if one parent
smokes, and almost fivefold if both parents smoke.
Some 70 percent of the children in this country live
in homes with at least one adult smoker.20 Exposure
to tobacco smoke is more harmful in children than
in adults, since growing tissue is more vulnerable to
carcinogens.
ETHICAL AND LEGAL IMPLICATIONS
The standard reference book, Clinical Toxicology
of Commercial Products, 5th Edition, assigns nic-
otine a toxicity rating of 6, “super toxic,” the highest
designation of toxicity, and describes nicotine as
“one of the most toxic of all poisons acting with great
rapidity.”’1 This poison enters the body of everyone
exposed to environmental tobacco smoke. With one-
third of the nation still smoking, it is difficult to find
someone with no nicotine in his blood. Yet, nicotine
is only one among “a total of 4,720 compounds”
found in tobacco smoke. Containing 13 billion par-
ticles per cubic centimeter, tobacco smoke is “one
of the most highly concentrated aerosols known.” It
is “10,000 times more concentrated than the aerosol
resulting from automobile pollution at rush hour on
a freeway.”’2
Right of the nonsmoker. Putting aside the issue
of bodily harm, should the nonsmoking majority of
the population tolerate exposure to air polluted by
the smoking minority? Do nonsmokers have to have
nicotine in their blood? Do they have to inhale
cyanide, carbon monoxide, acrolein, formaldehyde,
arsenic, benzene, nitrosamines, radionuclides, and
the thousands of other poisons and carcinogens con-
tained in a daily average dose of 1.4 milligram of
particulates and a large amount of gaseous matter2'1
which, as the tobacco industry asserts, may cause
the “healthy nonsmoker” only “transitory discom-
fort,” but “no serious harm” or “lasting adverse
health effects?”” Is there such a thing as the right
of a citizen to unadulterated air in places where he
has, or simply wants, to be? Lower federal courts
have decided that there is no constitutionally
protected right to breathe air that is free from
tobacco smoke contamination, yet the United States
Supreme Court never has ruled directly on this
issue,’4
Curiously enough, these questions rarely are
asked. Perhaps they have no place in our technologi-
cal civilization where science, pretending to be neu-
tral, is nevertheless the acknowledged arbiter of
social issues. A case in point is the proposition that
nonsmokers have to document, with “irrefutable
scientific evidence,” to have sustained physical in-
jury, before public policy measures should even be
considered.” The grotesque subversion of common
sense can even maintain that the “changes in airway
function reported for environmental tobacco smoke
exposure have not been proved to have any physio-
logic or clinical consequences.”” The role of science
in public health matters is not to seek exhaustive
final proof, but to gather sufficient evidence to jus-
tify political action. The evidence for the potential
harm of involuntary smoking is compelling,66 and
comprehensive legislative measures to protect the
public are overdue. Widely scattered local and re-
gional smoking regulations have been slow in coming
and have been achieved in piecemeal fashion and
only by battling against the fiercely defended
tobacco interests. While public attention has been
preoccupied by chemical hazards of minor impor-
tance, e.g. saccharin, whose carcinogenic potency
is 1/50,000 that of a single constituent,
benzo(a)pyrene, in cigarette smoke, tobacco has
been cunningly steered through perilous rapids and
continues to pollute us.
Where do we go from here?
Legal recourse. Those few who were desperate
enough to turn to the courts for relief because work-
place smoking conditions caused them acute physi-
cal distress found that their options were limited.7'834
If the nonsmoking plaintiff succeeds in demonstrat-
ing that tobacco smoke is harmful both to himself
and to other nonsmokers, the court might recognize
the employer’s common law duty to provide the
same safe and healthful working conditions accorded
sensitive electronic equipment, in whose vicinity
smoking strictly is prohibited. Failing this, the em-
ployee might qualify for “handicapped” status
under the Federal Rehabilitation Act of 1973 and
receive the privileges decreed by the Act, be awarded
disability retirement, or quit the job and earn un-
employment compensation. However, the possibility
of being fired must not be ignored. These latter op-
tions could label a normal, healthy individual,
whose only “shortcoming” is to be unable to function
in a smoke-polluted environment, as incapacitated
and abnormal, reflecting today’s twisted values. In
case the plaintiff finally decides to sue for damages,
the company can claim immunity under the
Workers’ Compensation Act, which denies com-
pensation for tobacco smoke exposure since the lat-
ter qualifies neither as an “injury” nor as an “oc-
cupational disease.”’4
NE^ERS^^EDICINE
314
Future prospects. At this juncture, a realistic ap-
praisal of our present state of affairs is in order. Is
public health policy, in fact, an issue of health based
on scientific evidence? If so, why is action not com-
mensurate with current knowledge? Except for some
members of the legal professions and a few starry-
eyed scientists who still believe in the Newtonian
fairytale of simple causation, no one doubts that the
link between smoking and disease has been firmly
established. Hence, the perennial battle cry for more
research and proof is a sham. The Tobacco In-
stitute’s disparagement of Dr. Everett Koop’s Re-
port on Involuntary Smoking, alleging that it con-
stitutes “a direct threat to scientific integrity” and
an “attempt to stifle free speech and academic free-
dom,”16 is shameless deceit aimed at confusing the
general public and legislative bodies. The Institute’s
rally to uphold the smokers’ inviolate right to smoke
has an equally hollow sound. The whole issue, in
short, is not one of health, biomedical science, and
freedom of choice, but one of profit at any price. The
multinational tobacco oligarchies and their merce-
naries care for people’s health and liberties only to
the extent that their victims survive long enough to
boost the consumption of the deadly merchandise.
Dispelling myths and facing facts will be the in-
dispensable first steps to educate the public and
prepare for rational action.
A fundamental change in our health policy could
be achieved simply by eliminating favoritism, dis-
honesty, and double standards when dealing with
chemical products. If tobacco and tobacco smoke
were subjected to the same legal scrutiny as most
other hazardous substances, the ensuing regulatory
decisions would swiftly clear and clean the air. Sec-
tion 112 of the Clean Air Act calls for regulation of
pollutants which reasonably may be anticipated to
result in an increase in mortality or an increase in
incapacitating reversible illness.7,8 This ruling seems
tailormade to deal with tobacco smoke. Its histori-
cal application by the Environmental Protection
Agency (EPA) to outdoor control probably is due to
the incorrectly made assumption that outdoor air
composition determines indoor air quality. Nowhere
in the law is it specified that it cannot be applied
to the indoors. Indoor violation of air quality stan-
dards for a number of substances occurs frequently
and would trigger an immediate pollution alarm if
it happened in the outdoor environment. Since
smoking is the major culprit, a simple smoking ban
in indoor public and workplaces could solve a com-
plex pollution problem with one stroke. All that is
needed is a comprehensive federal ruling and its
enforcement. Getting it on the agenda and eventu-
ally getting it passed necessitates a widespread, con-
certed, tirelessly repeated effort by the American
citizenry, led by a determined health professional
community. According to several opinion polls, even
many smokers favor smokeless places;17 their cooper-
ation also could be enlisted.
Since so much time is spent by Americans in oc-
cupational settings, the Occupational Safety and
Health Administration (OSHA) which regulates the
workplace, is the logical target for legislative action.
Enclosed public areas are workplaces for those who
maintain them. The general duty clause of the Oc-
cupational Safety and Health Act of 1970 states in
Section 5(a): “Each employer shall furnish to each
of his employees employment and a place of employ-
ment which are free from recognized hazards that
are causing or are likely to cause death or serious
physical harm to his employees.” To fulfill this man-
date, the problem of smoking would have to be ad-
dressed, yet OSHA so far has dodged its responsi-
bility.18 A recent citizen petition to classify tobacco
smoke as a potential occupational carcinogen — the
International Agency for Research on Cancer has
designated tobacco smoke as a human carcinogen19,40
— was denied by OSHA by stating in reply that
“tobacco smoke is not one of the priority substances
that OSHA has identified for consideration in the
development of standards” and that tobacco smoke
is not an agency priority because “tobacco smoke is
not generated by an industrial process.”41
Without action at the federal level, smoke-free
public places will emerge in a slow, laborious, and
haphazard fashion. Individual businesses so far have
been in the forefront, having discovered that going
smoke-free brings substantial monetary rewards.42
Hospitals seem to be last. It is a tragic irony that
all hospital-acquired flame burn deaths in California
resulted from cigarette-ignited fires.41
CITIZEN ACTION
What can an informed citizenry do to reduce the
widespread tobacco smoke pollution and its adverse
health effects? We must raise awareness through
education in an area where craftily engineered il-
lusion, deception, and ignorance have worked hand-
in-hand with our natural inclination toward indif-
ference and apathy. It is not easy to accept that what
has been viewed as right and normal, in fact, is
wrong, abnormal, and requires remedial action.
Educational efforts should start in kindergarten and
continue throughout the school years. It is im-
perative that tobacco be included, in content as well
as by name, in all projects and programs currently
restricted to “drugs and alcohol.” Health pro-
fessional education on tobacco, which presently is
inadequate,44 should prepare doctors and nurses for
determined action on an individual basis as well as
in the public arena. Smoking has emerged not only
as the single most important preventable cause of
premature disease and death in our society but also
VOL. 87— NUMBER 4 APRIL 1990
315
as the single most important preventable source of
exposure of the nonsmoking population to harmful
indoor air pollution.
The overriding goal should be the elimination of
tobacco smoke from all enclosed air spaces where
nonsmokers and smokers mix. The most expedient
way to achieve this objective would be by a federal
statute covering all enclosed workplaces, schools,
daycare centers, health care facilities, and public
areas across the nation. This could be achieved by
mandating an indoor air quality standard to reduce
carcinogenic risk to the maximum level of 1 in
100,000 considered acceptable by federal regulatory
agencies for environmental carcinogens in air, water,
or food.4* Elimination of tobacco smoke exposure in
private homes must be left to individual initiative.
A ban on smoking in the automobile, where high
exposure is possible, has been recommended by a
British member of parliament who views the distrac-
tion of lighting a cigarette as a cause of traffic acci-
dents.46 No-smoking must be made the norm without
posting signs, while physically separate smoking
areas should be so designated. Thus, instead of al-
lowing smoking unless specifically forbidden, the
general rule would be that smoking is prohibited
unless specifically allowed. This “rule-switching”
approach, which was first implemented in Finland,47
would go a long way toward debunking the myth
that smoking is normal behavior.
Before we can clear the air of tobacco smoke, we
will have to remove the smokescreen that powerful
tobacco interests have laid across this nation. Any
hostility between smokers and nonsmokers is inten-
tionally stirred and exaggerated by inflammatory
language in industry-controlled publications. We
should win the smoker as an ally on the side of
reason and responsibility. In a dispassionate
analysis of the question of rights, one can per-
suasively argue that while the right of the smoker
to smoke may cause injury to the nonsmoker, the
right of the nonsmoker for smoke-free air will not
harm the smoker.
CONCLUSION
The toll of suffering and dying exacted from un-
told millions of smokers around the globe is tragic
enough, but we now have compelling evidence that
smoking leaves a trail of disease and death also
among nonsmokers who are exposed to the poisons
and carcinogens discharged by billions of smoldering
cigarettes in enclosed air spaces. The resulting in-
door air pollution far exceeds the safe air quality
standards which, as yet, have been applied only to
the outdoor environment. Involuntary exposure to
tobacco smoke is not a mere health issue but
provokes serious ethical questions. In an editorial in
The New York Times in March 1985, Dr. William
G. Cahan identified smoking as the most prevalent
form of child abuse.4" Tobacco industry’s spokes-
persons maintain that adverse health effects have
not been demonstrated for environmental tobacco
smoke exposure49 as they persist in their denial that
smoking itself causes cancer, emphysema, and heart
disease.60,61 For them, neither active nor passive
smoking is truly an issue of health, scientific proof,
freedom of choice, or individual right, but simply a
poorly disguised matter of making money.
Thanks to dedicated individual and group in-
itiatives, progress has been achieved in raising pub-
lic awareness and restricting smoking to protect the
nonsmoker.62 However, the investment of time and
effort has not been matched by results, due to the
formidable opposition by tobacco interests. Du-
plicity in governmental policy also has impeded pro-
gress. Tobacco industry’s maneuverings are calcu-
lated to ride out the current wave of health-promot-
ing reforms, anticipating another calm period of con-
spicuous consumption. We must be on guard not to
let the present propitious momentum subside. In
this author’s opinion, the time has come to proceed
from the slow advance of local skirmishes so aptly
led by the nonsmokers’ rights movement,62 to a much
broader offensive at the federal level.
The benefits of such a policy to society will be
many. Exposure of nonsmokers to tobacco smoke
will decrease; smokers will smoke less or decide to
quit; quitters will be more successful and less prone
to relapse; greatly decreased visibility of smoking
will attract fewer young people to the ranks of
smokers; cigarette-induced fires and burn injuries
will dwindle; employers and building administrators
will reap large savings in maintenance and insurance
costs. Within the next 30 years, for the first time in
a century, cancer rates will diminish.
The present situation is clear. The accumulated
evidence is sufficient not only to suggest but to man-
date public health measures. Waiting for additional
injury before action is taken is unthinkable in a
civilized society. Being exposed to the smoke of
others differs from actively smoking only in intensity
of exposure. Hence, not granting the nonsmoker a
smoke-free space is tantamount to making smoking
mandatory for everyone. ■
Submitted: May 1989;
Accepted: September 1989
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PL: The fetal tobacco syndrome. JAMA 253:2998-2999,
1985.
27. Rubin DH, Leventhal JM, Krasilnikoff PA, Weile
B, Berget A: Effect of passive smoking on birthweight.
Lancet 2:415-417, 1986.
28. Smith N, Austen J: Tertiary smoking by the fetus.
Lancet 1:1252, 1982.
29. Rona RJ, Florey CV, Clarke GC, Chinn S: Parental
smoking at home and height of children. Br Med J
283:1363, 1981.
30. Sandler DP, Everson RB, Wilcox AJ, Browder JP:
Cancer risk in adulthood from early life exposure to
parent’s smoking. Am J Public Health 75:487-489, 1985.
31. Clinical Toxicology of Commercial Products, 5th
Edition. Baltimore, MD, Williams and Wilkins, 1984.
32. Dube MF, Green CR: Methods of collection of
smoke for analytical purposes. Recent Advances Tobacco
Science 8:42-102, 1982.
33. Tobacco Institute: Smoking and Health 1964-1979:
The Continuing Controversy. Washington, DC, 1979, pp.
13-33.
34. Paolella RL: The legal rights of nonsmokers in the
workplace. Univ Puget Sound Law Review 10:591-632,
1987.
35. Huber GL: Letter to the editor. N Engl J Med
303:392, 1980.
36. Marshall, E: Tobacco science wars. Science
236:250-251, 1987.
37. Survey of attitudes towards smoking. Smoking and
Health Reporter, January 1986.
38. Kotin P, Gaul LA: Smoking in the workplace: A
hazard ignored. Am J Public Health 70:575-576, 1980.
39. Vainio H, Hemminki K, Wilburn J: Data on the
carcinogenicity of chemicals in IARC monographs.
Carcinogenesis 6:1653-1665, 1985.
40. Ginzel KH: The “defect” in tobacco: A biomedical
analysis. Tobacco Product Litigation Reporter 2.5 TPLR
5.63-5.76, 1987.
41. Smoking: OSHA denies citizen petition to regulate
workplace tobacco smoke. Occupational Safety and
Health Reporter, Current Report. The Bureau of National
Affairs, Inc., Feb. 25, 1987, pp. 1022-1023.
42. Martin MJ, Fehrenbach A, Rosner R: Ban on smok-
ing in industry. N Engl J Med 315:647, 1986.
43. Bongard FS, Ostrow LB, Sacks ST, et ah: Fatal
hospital-acquired burns. JAMA 252:2813, 1984.
44. Ginzel KH: The underemphasis on smoking in
medical education. NY State J Med 85:299-301, 1985.
45. Repace JL, Lowrey AH: An indoor air quality stan-
dard for ambient tobacco smoke based on carcinogenic
risk. NY State J Med 85:381-383, 1985.
46. Johnston P: Squeezing the smoker. Br Med J
292:215, 1986.
47. Roemer R: Legislative action to combat the world
smoking epidemic. World Health Organization, Geneva,
1982.
48. Cahan WG: Abusing children by smoking. The New
York Times, March 9, 1985.
49. Conference on the experimental toxicology of pas-
sive smoking, Essen, Germany, 1986. Toxicol Letters
35:1-168, 1987.
50. Kornegay HR: The cigarette controversy. En-
gage/Social Action, September 1980, pp. 27-31.
51. Interview of Gerald H. Long, President of R.J. Rey-
nolds Tobacco Co. A loyalist views tobacco’s fate. Insight,
May 19, 1986, p. 15.
52. Glantz SA: Achieving a smokefree society. Circula-
tion 76:746-752, 1987.
VOL. 87— NUMBER 4 APRIL 1990
317
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318
NEW JERSEY MEDICINE
Idiopathic Chronic
Fatigue
A Primary Disorder
ROBERT J. VAN AMBERG, MD
Idiopathic chronic fatigue, an entity worthy of attention, understanding, and
treatment, has disappeared from medical and psychiatric publications. None-
theless, it is an important clinical phenomenon.
Inexplicable, disabling fatigue, chronic and re-
sistant to treatment, is a troublesome medical
and psychiatric problem. Nineteenth-century
treatises by Beard,1'4 Mitchell,5 daCosta,6 and Burr'
make clear that chronic fatigue syndromes were
common, their causes speculative, and treatment
difficult. Their terms, “neurasthenia,” “nervous ex-
haustion,” “chronic fatigue,” and “neurocireulatory
asthenia” have been used interchangeably to the
present time to label a variety of functional organ
system disorders and emotional states that share
swift fatigability and unknown etiology.
In the 20th century, the most popular term, “neu-
rasthenia,” w'as stripped of all symptoms except
fatigue and became synonymous with it.8'9 But ex-
cessive fatigue by any name had become of so little
diagnostic value in both psychiatry and medicine
that neurasthenia had no listing in the American
Psychiatric Association’s first Diagnostic and
Statistical Manual (DSM) in 1952lfl and lost its place
in the indices of medical textbooks.
Dr. Van Amberg is affiliated with The Mountainside Hos-
pital, Montclair. Requests for reprints may be addressed
to Dr. Van Amberg, 1 Russell Terrace, Montclair, NJ
07042.
Neurasthenia returned to DSM II in 196311 in def-
erence to the continued use of the term in Europe,8
but with DSM III in 1980, 12 fatigue as a phenomenon
in its own right disappeared. It was assigned to other
disorders such as depression and anxiety.
In the meantime, fatigue — not ascribable to any
identifiable disease — was deemed by medicine to be
psychological or emotional; thus, it was left to psy-
chiatry. Presumably, if some new disease was found
that seemed to account for hitherto unexplainable
fatigue, that disease would become medicine’s re-
sponsibility. Accordingly, over the past few decades,
textbooks of medicine gradually have dropped
chronic fatigue per se from consideration. Standard
textbooks of medicine reserve fatigue to clearly
diagnosable diseases.1315
Chronic inexplicable fatigue never has ceased
being a problem in clinical practice, as evidenced by
sporadic contributions to the medical press.16'32 Hart,
in French’s Index of Differential Diagnosis, after
stating that there is “no end of medical disorders
that may cause fatigue,” lists unhappiness,
boredom, overwork, being overwrought, and excess
physical and mental activity as nonillness causes.33
This suggests that fatigues unrelated to identifiable
disease still may be of concern to medicine.
VOL. 87— NUMBER 4 APRIL 1990
319
Halberstam, in Conn’s Current Diagnosis, 7th
Edition, is more vigorous in his view that fatigue is
medicine’s responsibility.14 Charging that medicine
has neglected the problem, he writes, “If you would
like to know the epidemiology and differential
diagnosis of fatigue as the presenting symptom in
office practice, don’t bother checking the standard
medical literature. I have, and it is worthless. There
is no more telling indictment of academic medicine
and its separation from the real world of patient care
than the articles listed under ‘fatigue’ in Index
Medicus. . . . There is next to nothing on fatigue in
clinical practice . . . from 1966 to 1978 not a single
article appeared with any actual data on the out-
come of tired patients.” The same can be said for
1979 through 1987.
Halberstam and his two colleagues resolved to
“remedy this lack.” They gathered data on a large
number of patients tired for over one month (some
for over two years), and all, but a few “rarities,”
without discernible illness. Thus, they join the scat-
tering of physicians who have drawn attention to the
problem.29 32
A few years ago, chronic fatigue as an important
symptom received renewed recognition by way of
Epstein-Barr virus (EBV) testing. With the means
to measure titers of EBV antigens and antibodies,
attempts have been made to correlate these findings
with signs of disease.35'38 Since it is well known that
extraordinary fatigability is a prominent feature of
infectious mononucleosis, an EBV viral infection, it
has seemed logical to test chronic fatigue patients
for such an infection. As a result, tired persons with
equivocal EBV titers have appeared in substantial
numbers, the source of their fatigue still in question.
Current interest in the fatigue-EBV complex il-
lustrates the difficulties medicine has in coming to
grips with chronic fatigue. Since fatigue is accepted
only as a manifestation of a disease, either identi-
fiable now or to be recognized eventually, clinical
attention is directed to that particular disease’s
symptom complex and a search is made for its
etiology. Thus, investigation of fatigue itself is
precluded.
Psychiatry also has set fatigability aside by lock-
ing it into several separate syndromes.12 As with the
medical model, it is assumed that treatment of the
syndrome is sufficient for the associated fatigue and
that concern for fatigue itself is irrelevant.
The changing perspective of chronic fatigue over
the past few decades from primary disease to second-
ary factor of some other disease brings us to an
awkward clinical point. Most patients regard their
inexplicable fatigability as probably harmless but
sorely frustrating, physical in nature, especially
puzzling in its persistence. At the same time, phy-
sicians facing the problem have no sure way to
understand and assess fatigue beyond the intensity
of the patient’s complaint. There is no standard
treatment. In fact, there is doubt that fatigue is
treatable medically or even that it should be treated.
Referral to psychiatric care is not a reasonable way
out unless a patient has prominent emotional symp-
toms. As patients continue to press their complaint
on physicians insufficiently prepared to treat it, it
becomes evident that idiopathic chronic fatigue
should be reconsidered and closely examined.
CONCEPT OF IDIOPATHIC CHRONIC FATIGUE
Reconsideration starts with the development of a
concept of idiopathic chronic fatigue, and an ap-
propriate starting point is the patient’s complaint.
It may be expressed subjectively (as feeling tired),
behaviorally, or physiologically, implying an ab-
normal condition.
These three aspects of fatigue have made a simple
concept of clinical fatigue difficult to form. As popu-
larly used, fatigue means feelings of at least a few
different kinds and impairments of numerous men-
tal abilities, motor skills, and particular powers.
Subjective fatigue rarely corresponds closely to the
fumbling and mistaken actions said to be due to
fatigue. Although loss of energy is thought to be the
reason for being tired, there is no recognized
pathophysiologic evidence to support the idea.
Medicine and psychiatry, by using fatigue in its
colloquial sense, are caught up in its confusion.
To cut through the confusion and to clarify the
clinical problem, a definition of fatigue in its usual
sense is a necessary first step. This definition must
include fatigue’s subjective, behavioral, and physio-
logical aspects in the contexts of generally accepted
fatigue, such as: physical fatigue, mental fatigue,
emotional fatigue, general or “overall” fatigue; ob-
jectively specified muscular fatigue and more lo-
calized fatigues such as tired back, tired legs, and
tired eyes; and the categorically different sleepiness
and the fatigue of boredom. An all-inclusive defi-
nition may read: “Fatigue is a condition, manifested
by various vague, disagreeable feelings and/or
diminished abilities, brought on by prolonged or
strained effort, and corrected by cessation of that
effort.” To this general statement, several corollaries
should be added: the disagreeable feelings may be
of all voluntary functions or may be limited to cer-
tain muscle groups, sensory systems, and/or particu-
lar intellectual functions; these disabilities may be
barely appreciable or virtually immobilizing; and
recovery may be almost immediate upon cessation
of the strained effort or may be delayed a day or two.
This definition is designed to cover fatigues that
are experienced universally and without undue per-
sonal concern; it does not cover the fatigue patients
see as worrisome and different, where patients ex-
320
NEW JERSEY MEDICINE
ll
perience unduly swift onset of discomfort and dis-
ability after the start of activity. The subjective fac-
tor is intensified; the fatigue feels unusually dis-
agreeable. More functions are impaired, and for all
activities, stamina is reduced sharply. Recovery of
energies is long delayed and incomplete.
Therefore, pathological fatigue may be defined by
a modification of our basic definition: “Pathological
fatigue is a condition manifested by various vague,
exceptionally unpleasant feelings, and/or extraor-
Trauma victims have exhibited a similar spec-
trum of fatigability. The seemingly same injuries
sustained in an automobile accident may not fatigue
some persons at all, and others may be invalid by
exhaustion for months or years.
Pregnancy and parturition also pose fatigue and
weakness problems. It is expected that a prolonged,
difficult labor may cause an exhausted, wearied con-
dition for weeks, if not months; for some, the return
of energy may take years. Numerous, closely spaced
Fatigue is a condition, manifested by various vague, disagreeable feelings,
that may be limited to certain muscle groups, sensory systems, and/or
particular intellectual functions; these disabilities may be barely appreciable
or virtually immobilizing; and recovery may be almost immediate upon cessa-
tion of the strained effort or may be delayed a day or two.
dinarily diminished abilities, brought on by moder-
ate or slight effort, and not corrected in a reasonable
time after stopping the activity.”
Our particular concern, idiopathic chronic fatigue,
is a special case of pathological fatigue having two
additional features: its cause is unknown or at best
speculative, and duration is much prolonged.
While our definitions of pathological fatigue and
idiopathic chronic fatigue may spell out component
parts and features that distinguish it from nonillness
fatigue, they are of no practical help clinically. They
give as much importance to subjective aspects as
they do to objective behavioral aspects. The clinical
problem is diffusely unfocused. Further, the im-
plication of some physiological abnormality, pos-
sibly several different kinds, leads nowhere.
FATIGUE-ASSOCIATED CONDITIONS
The suspicion that there may be different fatigue
states arises from the recognition that different dis-
eases are associated with different patterns of
fatigue. The fatigues of infections of the upper res-
piratory tract and of the gastrointestinal tract are
hardly remarkable; recovery from these infections
usually brings a quick return to normal strength and
stamina. A different pattern is illustrated by
notoriously tiring infections such as hepatitis, mod-
erately severe infectious mononucleosis, and swiftly
recurring upper respiratory infections. Energy return
may be delayed for a year or more after all clinical
and laboratory signs of illness have reverted to nor-
mal. Some patients insist years later that they never
did fully recover from these particular illnesses.
Common surgical procedures may cause a range
of energy aberrations.'19 Operations such as chole-
cystectomy and hysterectomy, even herniorrhaphy,
may cause some patients weakness and weariness for
a week or two. Others suffer for several months.
pregnancies are expected to drain most women, but
there are those who become irreparably fatigued
after two or three well-spaced, normal pregnancies.
The abnormally severe and prolonged fatigues of
these particular medical, surgical, and obstetrical
patients are clinically indistinguishable from one
another. In none is the failure to regain strength
understood, and as the origins of the conditions are
lost sight of over time, the patients tend to be placed
in the categories of emotional disorders. There is
good reason for this because their illnesses are indis-
tinguishable from chronic fatigue states that have no
plausible origin — fatigues of psychiatric syndromes.
While medicine may feel it has completed its work
by referring undiagnosable fatigue patients to psy-
chiatry, psychiatry has been undergoing an uncer-
tain struggle over what to do. After decades of being
a major part of, even the essence of “neurasthenia,”
chronic fatigue made a tentative appearance as a
physiologic abnormality with DSM I in 1952. 10 The
term received primary disorder status as “psy-
chophysiologic nervous system reaction,” a label
that never gained acceptance. Eleven years later, it
was replaced by a resurrected “neurasthenia” in
DSM II. 11 But “neurasthenia” no longer was useful,
because psychiatry held fatigability to be a mani-
festation of anxiety and depressive disorders.8-9 Since
this change was not yet officially recognized, during
the term of DSM II (1963-1980), chronic fatigue for
all practical purposes disappeared. It returned in
DSM III to be seen as a consequence of or part of
several disorders: major depressive episode, dys-
thymic disorder, and general anxiety disorder.
By placing chronic fatigue within the major de-
pression syndrome, psychiatry gives a strong indica-
tion that it is a physiological phenomenon. Among
the symptoms that may permit such a diagnosis is
“fatigue or loss of energy every day.”6 The manual’s
VOL. 87— NUMBER 4 APRIL 1990
321
narrative points to a “decrease in energy level — a
sustained fatigue.” Dysthymia also may be charac-
terized by “low energy level or fatigue.” Generalized
anxiety disorder subgroup “motor tension” lists easy
fatigability as one of four possible symptoms needed
to establish a diagnosis.
DSM III — Revised brings back classical neu-
rasthenia with a new name, undifferentiated
somatoform disorder.^ The diagnosis may be made
with “one or more physical complaints, e.g. fatigue,
loss of appetite, gastrointestinal or urinary com-
plaints . . . anxiety and depressed mood are com-
mon.” Since one symptom is sufficient for the
diagnosis, fatigue appears to have forced its way
back as a primary phenomenon, although camou-
flaged by another designation not likely to become
popular.
WORKING DEFINITION
These medical, surgical, obstetrical, traumatic,
and psychiatric fatigues may be proved to have a
common pathophysiology. But this is as uncertain
as their etiologies. Therefore, clinicians now must do
with as clear a symptomological concept as possible
that renders chronic fatigue objective and manage-
able. The definitions formulated above, with their
mix of subjective, behavioral, and physiological fea-
tures should be examined as a logical next step for
the possible extraction of a single factor that could
be regarded as the essence of fatigue.
The subjective complaint cannot be that factor
because, as with any report of a subjective ex-
perience, feelings are difficult to identify and ap-
praise. One person’s sensations can be compared to
another’s only approximately and with great uncer-
tainty.
Assessment of a particular patient’s fatigue state
by clinical observation also is unreliable. A patient
may appear and sound tired, but in a short while
may change and look and sound well. Or he may
appear very well at the physician’s office only to be
very tired everywhere else.
To attack the problem at a physiological level may
seem a possible approach, since the loss of power to
maintain a particular level of performance and an
inability to recover strength in an expected time
imply an energy deficit or some other physiological
disorder. But the clinical phenomenon is so varied
in form and extent that no characteristic
biochemical abnormalities have been identified with
any certainty.
The “diminished abilities” aspect of fatigue can-
not be used as the essential factor because whatever
particular ability or abilities may be selected as rep-
resentative of all fatigues easily would be challenged
as nonrepresentative of the others.
However, if “abilities” were seen as “ability,” that
is, the state of being able, the common denominator
of all fatigues would be at hand. The disability of
all fatigues first exhibits premature decrements of
dexterity, then a premature strained effort and fi-
nally, shortened duration of action. “Diminished
ability,” therefore, means the diminished ability to
maintain effort, i.e. diminished stamina.
Pared to this essential factor, a working definition
of all chronic fatigues may read: “Pathological
fatigue is a prolonged condition of diminished
stamina manifested by various subjective symptoms
and impaired abilities.”
Idiopathic chronic fatigue is a pathological
fatigue, i.e. a prolonged condition of diminished
stamina, the cause of which is unknown. Within this
diagnosis are those fatigues that at their onset may
have been associated with medical, surgical, ob-
stetrical, or traumatic condition but over time have
taken a course of their own and thus have become
idiopathic. The etiology of so-called psychological
fatigue, whether said to be inner conflict or external
stress, still is speculative so that, for the present,
these fatigues also are idiopathic. And, it would not
be surprising if some of the fatigues within psy-
chiatric syndromes turned out to be idiopathic.
IDIOPATHIC CHRONIC FATIGUE ASSESSMENT
Once identified as the key to understanding
pathological fatigues, stamina requires objective
measurement. This measure is needed to: establish
the existence of the problem; distinguish minor
problems from the more severe; and set the stage for
realistic management. Unfortunately, we have only
approximate means of assessing fatigue.
A few patients given to strenous physical activity
may well quantify their disability by comparing
what they used to do with what they do now. A
tennis player who routinely went three or four sets
barely can last for two sets. A landscape gardener
who could work 12 hours a day and six days a week
feels at the edge of collapse after 3 hours.
But not many patients have specific activities that
easily lend themselves to numbering hours or
minutes of staying power. An office job of eight hours
or the care of a home and children that may have
been easily carried out now cause strain at some
periods during the day. It is difficult to say how
many periods each day and how long each period is.
For most people, these periods of tiredness blend
into one another on any given day and throughout
the week. Patients know, however, that they are not
functioning with their usual effectiveness. They also
become aware that they do not have the energy of
everybody else. Such observations are much too sub-
jective and general to enable a physician to take a
measure of their fatigue.
To frustrate the assessment further, many people
322
NEW JERSEY MEDICINE
have misleading self-evaluations of fatigue. A person
who says “I have been tired all my life” may consider
a state of marked disability as normal, while a per-
son who feels compelled to keep up with an extreme-
ly energetic close associate may feel his average
stamina to be distressingly insufficient. Stoics deny
fatigability; worrywarts exaggerate it.
Any attempt to get a measure of a patient’s
stamina must circumvent these obfuscations, while
the subjective and partially objective generalities
are made more specific and tangible. This can be
done to a helpful degree by having the patient make
close observation of the onset and passing of fatigue
throughout a few typical days. Although this process
by no means eliminates the subjective element, it
does induce patient and physician to think about
fatigue as objectively as possible. These observations
permit fatigue to be graded on a six-level scale:
Level I. Periods of unusually vigorous activity are
interspersed with immobilizing fatigue.
Level II. Tiredness persists for one-half to two
hours after arising; return of tiredness mid- or late-
afternoon for one to two hours; early evening fatigue.
Level III. Tiredness is noticeable most of the day.
Level IV. Ordinary tasks are a strained effort;
energy is available for only important matters.
Level V. Every activity is a distressed, struggling
effort.
Level VI. Exhausted; sofa-bound; and bedridden.
A few patients will find their fatigue patterns
closely matching just one of the six levels. Each
patient is unique in the routine of daily activities,
in the demands put upon him, and in the appear-
ance and fading of fatigue symptoms. Therefore,
most fatigue patterns only approximate one of the
six identified levels and may even be seen to shift
between two levels.
Stamina impairment of patients at levels I and II
obviously is so grossly different from that of patients
at levels V and VI that concern about obtaining a
quantitative measure hardly seems worthwhile. But
levels II, III and IV, the most common fatigue levels
presented to a physician, are difficult. It is at these
levels of fatigability that an objective test is required
to identify the impairment and its degree; the test
would be called upon to measure a person’s en-
durance powers for ordinary daily activities.
DISCUSSION
For clinicians long-pressed to treat its myriad
forms, chronic fatigue’s checkered career has been
as dramatic as it has been bewildering. Late 19th-
century publications colorfully scrambled physiol-
ogic concepts with nervous system and emotional/
psychological constructs. Into the 1930s, medicine
was treating chronic fatigue as a physiologic disorder
with emotional overlays,41 while psychiatry was
treating the same disorder, then called neu-
rasthenia, as a neurotic disorder with some physical
manifestations. Although speculative unconscious
conflicts and other conjectural mental factors were
held to be causes of neurasthenia, physical rehabili-
tative measures were briefly added to psychiatry’s
chief treatment method, psychotherapy.
Any physical treatment measure that enhanced a
patient’s vitality was seen as “adjunct” to psy-
chotherapy. When World War II combat exhaustion
centers were ordered to use 40 to 50 units of insulin
daily in treating large numbers of psychiatric com-
bat casualties,42 it was evident that the surgeon gen-
eral and his psychiatric consultants saw physical
measures fully as important as psychotherapy, if not
more so, under war time stringencies.
Physical exhaustion lost its cachet after the
war.4243 Combat exhaustion was to be given a civilian
diagnosis. The symptoms of anxiety and depression,
common features of combat exhaustion, dominated
the syndromes and fatigue became secondary, even
incidental.
During the past few decades, family physicians
with improving diagnostic means have been able to
identify with confidence those chronic fatigue pa-
tients who have no discernible disease. Since these
patients are presumed to be physiologically sound,
it would appear appropriate to refer them to psy-
chiatry. Psychiatry, meanwhile, has assigned fatigue
to discrete syndromes on which it focuses its atten-
tion: depression, dysthymia, anxiety, and somato-
form disorder. The role that fatigue plays in these
syndromes is quite different from that in medical
illness. Where the fatigues of medicine are a direct
result of the disease process, the fatigues of psy-
chiatry may be a result of the disorder, an important
contributory factor, or an irregularly appearing
manifestation.
The fatigue of depression is especially puzzling.
Retarded thoughts and heavy sluggish movements of
depression feel like tiredness, although there may be
no impairment of stamina. A long struggle against
depression might result in reduced stamina, the
fatigue unnoticeable in the context of depression.
Or, disabling fatigue day after day may lead to a
despondency barely distinguishable from de-
pression. In dysthymic states, the despair over
chronic fatigability is difficult to distinguish from
depression. In some anxiety states, patients may be
tired because they constantly are worried or may be
anxious because their powers are failing them.
Psychiatry’s wrestling with fatigue has come full
circle — from neurasthenia, to psychophysiological
nervous system reaction, to abandonment with a
gesture to neurasthenia, to assignment to syndromes
of depression, dysthymia, and anxiety, and back to
neurasthenia with a new designation, undifferen-
VOL. 87— NUMBER 4 APRIL 1990
323
tiated somatoform disorder. Changing labels peri-
odically has not furthered an understanding of
chronic fatigue. If this common clinical complaint
is to be understood and treated, it probably is best
to call it by its own name, chronic fatigue, and
consider it an entity by itself.
If we agree that a chronic fatigue state is theoreti-
cally possible, only a small first step will be taken.
Then come problems of identification, measure-
ment, etiology, pathophysiology, and treatment. Its
relationship to other illnesses must also be studied.
If we could agree on the presence of a chronic
fatigue state, it also could be a boon to an ap-
prehensive patient. It could reassure against the tor-
menting prospects of an undiagnosed lethal disease,
a mental breakdown or intolerable ridicule. We hope
our working definition of idiopathic chronic fatigue
and our method of assessment will enable physicians
and patients to work together to determine etiology
and evolve plans for management. ■
Submitted: June 1989; Accepted: September 1989
REFERENCES
1. Beard GM: Neurasthenia, or nervous exhaustion.
Bost Med Surg J 3:217-220, 1869.
2. Beard GM: American Nervousness, Its Causes and
Consequences. New York, NY, GP Putnam, 1881.
3. Beard GM: A Practical Treatise on Nervous Exhaus-
tion (Neurasthenia). New York, NY, William Ward, 1880.
4. Beard GM: A Practical Treatise on Nervous Exhaus-
tion (Neurasthenia), Edition 5. New York, NY, EB Treat
& Co., 1905.
5. Mitchell SW: Fat and Blood: An Essay on the Treat-
ment of Certain Forms of Neurasthenia and Hysteria,
Edition 3. Philadelphia, PA, -JB Lippincott, 1884.
6. daCosta JM: On irritable heart: A clinical study of
a form of functional cardiac disorder and its consequences.
Am J Med Sci 61:17-52, 1871.
7. Burr CW: Neurasthenia, in Osier W, Modern Medi-
cine. Philadelphia, PA, Lea & Febiger, 1910, pp. 721-738.
8. Chatel JC, Peel R: A centennial review of neu-
rasthenia. Am J Psychiatry 126:48-55, 1970.
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terworths, 1967.
10. Diagnostic and Statistical Manual of Mental Dis-
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Association, 1952.
11. Diagnostic and Statistical Manual of Mental Dis-
orders, Edition 2. Washington, DC, American Psychiatric
Association, 1963.
12. Diagnostic and Statistical Manual of Mental Dis-
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13. Wyngaarden JB, Smith LH: Cecil Textbook of
Medicine. Philadelphia, PA, WB Saunders Co., Harcourt
Brace Jovanovich, 1988.
14. Braunwald E, Esselbacher KJ, Petersdorf RG, et
al.: Harrison’s Principles of Internal Medicine, 11th
Edition. New York, NY, McGraw Hill Book Co., 1987.
15. Rakel RE: Conn’s Current Therapy. Philadelphia,
PA, WB Saunders Co., Harcourt Brace Jovanovich, 1988.
16. Shands HC, Finesinger JE: Note on the significance
of fatigue. Psychosom Med 14:309-314, 1952.
17. Friendlander HS: Fatigue as a presenting symptom.
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18. Ellis FR, Cox M: Fatigue — a clinico-pathological
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20. Michael SR: Normal and not-so-normal fatigue.
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.weakness and fatigue. Psychosom 21:19-24, 1980.
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25. Pateliakhoff A: Adrenocortical activity and some
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Res 25:91-95, 1981.
26. Jerrett WA: Lethargy in general practice. Practi-
tioner 225:731-737, 1981.
27. Montgomery GK: Uncommon tiredness among col-
lege undergraduates. J Consult Clin Psychol 51:517-525,
1983.
28. Morris JD: Fatigue as a presenting complaint in
family practice. J Fam Pract 10:795-801, 1980.
29. Solberg LI: Lassitude — a primary care evaluation.
JAMA 251:3272-3276, 1984.
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family practice. J Fam Pract 19:643-647, 1984.
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Fam Pract 2:48-53, 1985.
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Differential Diagnosis. Bristol, England, Wright, 1985.
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sisting illness and fatigue in adults with evidence of
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operative deterioration in psychomotor function. JAMA
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Psychiatric Association, 1987, pp. 266-267.
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Illness. New York, NY, London, Paul B. Hoeber, 1947.
324
NEW JERSEY MEDICINE
Report of the
Nominating Committee
Offices To Be Filled By Election: 1990 Annual Meeting
Office Term Nominee and County
Officer
President-Elect 1 year
1st Vice-President 1 year
2nd Vice-President 1 year
Trustees
1st District 3 years
3 years
2nd District 3 years
3 years
3rd District 3 years
3 years
4th District 3 years
Judicial Councilors
1st District 3 years
4th District 3 years
AMA Delegates
2 years
2 years
2 years
2 years
2 years
2 years
2 years
AMA Alternate Delegates
1 year*
2 years
2 years
2 years
2 years
2 years
2 years
Joseph A. Riggs, MD, Camden
William E. Ryan, MD, Mercer
Joseph N. Micale, MD, Hudson
Anthony P. Caggiano, Jr, MD, Essex
R. Gregory Sachs, MD, Union
Philip J. Jasper, MD, Passaic
Carl Restivo, Jr, MD, Hudson
Michael M. Heeg, MD, Mercer
Leticia V. DeCastro, MD, Middlesex
Angelo S. Agro, MD, Camden
Anita Falla, MD, Essex
George T. Hare, MD, Camden
Karl T. Franzoni, MD, Mercer
Frederick W. Durham, MD, Camden
Ralph J. Fioretti, MD, Bergen
Palma E. Formica, MD, Middlesex
John S. Madara, MD, Salem
Henry J. Mineur, MD, Union
Edward A. Schauer, MD, Monmouth
A. Ralph Kristeller, MD, Union
The Nominating Committee finds there are
seven excellent candidates available for the six
alternate delegate positions. The candidates
are: Doctors Joel S. Cherashore, PaulJ. Hirsch,
A. Ralph Kristeller, Joseph N. Micale, Irving P.
Ratner, Carl Restivo, Jr, and R. Gregory Sachs.
(Italics denotes incumbents.) The House will
decide which of these well-qualified members
shall serve.
Administrative Councils
Legislation
1st District
2 years
George J. Hill, MD, Essex
2nd District
2 years
No nominee named by the Nominating Committee
3rd District
2 years
Gabriel F. Sciallis, MD, Mercer
4th District
2 years
William V. Harrer, MD, Camden
Medical Services
1st District
2 years
Robert H. Stackpole, MD, Union
2nd District
2 years
Frederic E. Wien, MD, Passaic
3rd District
2 years
Ismail Kazem, MD, Mercer
4th District
2 years
Joseph W. Sokolowski, Jr, MD, Camden
VOL. 87— NUMBER 4 APRIL 1990
327
REPORT OF THE NOMINATING COMMITTEE
Office
Term
Nominee and County
Mental Health
1st District
2nd District
4th District
5th District
2 years
2 years
2 years
2 years
Rita R. Newman, MD, Essex
No nominee named by the Nominating Committee
Kenneth J. Rubin, MD, Monmouth
Terry A. Johnston, MD, Atlantic
Public Health
1st District
2nd District
3rd District
4th District
2 years
2 years
2 years
2 years
Richard R. Lorber, MD, Union
No nominee named by the Nominating Committee
Lawrence D. Frenkel, MD, Middlesex
Mary F. Campagnolo, MD, Burlington
Public Relations
1st District
3rd District
4th District
6th Member
2 years
2 years
2 years
2 years
Philip A. Rispoli, MD, Essex
Leticia V. DeCastro, MD, Middlesex
Blackwell Sawyer, Jr, MD, Ocean
Harry H. Brunt, Jr, MD, Monmouth
Standing Committees
Annual Meeting
2 years
2 years
John P. Mudry, MD, Bergen
Frank R. Romano, Sr, MD, Union
Finance and Budget
2 years
2 years
Julie M. Fortunato, MD, Bergen
No nominee named by the Nominating Committee
Medical Education
2 years
2 years
Paul C. Royce, MD, Monmouth
Anthony P. DeSpirito, MD, Monmouth
Membership Services
2 years
2 years
Donald J. Cinotti, MD, Hudson
Robert L. Maggs, MD, Monmouth
Publication
2 years
2 years
William V. Harrer, MD, Camden
Morris Soled, MD, Hudson
^Vacancy created by resignation of Bernard Robins, MD.
328
NEW JERSEY MEDICINE
■ TRUSTEES’ REPORT*
A regular meeting of the Board
of Trustees was held on Sunday,
February 18, 1990, at the executive
offices in Lawrenceville. Detailed
minutes are on file with the sec-
retary of your county society; a
summary of significant actions fol-
lows:
Report of the President . . .
(1) Professional Liability In-
surance . . . Brought attention to
Dr. Hirsch’s column in the March
issue of NEW JERSEY MEDI-
CINE, and noted the new mem-
bers of the Board of Directors of
the Underwriters: Drs. Carnes,
Hirsch, Palace, Riggs, and Rob-
inson.
(2) Awards . . . Congratulated Dr.
Fioretti as the recipient of the Doc-
tor of the Year Award from the
New Jersey Academy of Family
Practice; Dr. Fares as the recipient
of a humanitarian award from the
American Cancer Society; and Dr.
Maurer as the recipient of the Doc-
tor of the Year Award from the
New Jersey Osteopathic Society.
(3) Tort Reform . . . Noted Dr.
Maurer’s efforts on behalf of tort
reform.
(4) AIDS . . . Heard much dis-
cussion on the topic of AIDS, and
noted that the Academy of Medi-
cine of New Jersey is sponsoring a
seminar on AIDS at the MSNJ An-
nual Meeting, and noted three
major symposiums, “Identification
and Management of Asympto-
matic HIV-Infected Persons in
New Jersey,” would be sponsored
by the Academy, MSNJ, and
NJDOH.
(5) Medicare Reimbursement on
Unassigned Claims . . . Noted
that a letter was sent to New Jer-
sey congressmen objecting to the
new Medicare requirement that
physicians file claim forms for pa-
tients, and a memo was sent to the
AMA delegation requesting an ap-
propriate resolution be developed
regarding the requirement.
(6) AMA Council on Scientific
Affairs . . . Received and referred
to the AMA delegation a request
for endorsement of Dr. W. Douglas
Skelton, as a candidate for a posi-
tion on the AMA Council on Scien-
tific Affairs.
Report of Executive Director . . .
(1) Financial Statements . . . Re-
viewed and approved the financial
statements for the period ending
December 31, 1989.
(2) Legislation . . . Received com-
ments on the following: Fair Auto-
mobile Insurance Reform Act of
1990 (A-l; S-2295), and noted that
MSNJ needs to take a responsible
position regarding the issue of bal-
ance billing; physician-directed
physical modalities (A-546) and
noted MSNJ will assume a posi-
tion of disapproved on the basis
that the State Board of Medical
Examiners already has adopted a
ruling on physical modalities; and
Medicare mandatory assignment
(A-3042) and noted this bill almost
mirrors MSNJ’s senior courtesy
program.
(3) Litigation . . . Reviewed the
following: PRO versus MSNJ and
that William Cahill, Esquire, is
the attorney and discussions re-
garding possible settlement are
continuing with a June trial date
anticipated; MSNJ versus State
Board of Physical Therapy case
was heard in the state Supreme
Court in February; MSNJ versus
Merin and St. Paul Insurance
Company has billed for the
surcharge; State Board of Medical
Examiners versus Sinha and
MSNJ has entered the case
amicus; Clinical Laboratory Im-
provement Act and noted the De-
partment of Health is reviewing
New Jersey licensing requirements
for clinical laboratories; medical
waste registration fee refunds will
likely not be made before July 2,
1990; membership demographics
noted that 68.5 percent of MSNJ’s
dues-paying membership is 55
years of age or younger; construc-
tion of Underwriters’ Offices is
being completed and the balance
of funds will be held in reserve
until all work is completed.
Monthly Reports . . . Received re-
ports from UMDNJ, the New Jer-
sey Hospital Association, and the
Academy of Medicine of New Jer-
sey.
Council on Public Health . . . Ap-
proved the following recommen-
dation and also voted to expand
the recommendation to include flu
vaccination for children with
chronic lung diseases and other de-
bilitating diseases:
That the Society petition the Gov-
ernor, and Commissioners of Health
and Education, and the State Legis-
lature to intensify efforts to vaccinate
unimmunized children and to require
a second MMR vaccination for school
attendance; and that the Society re-
quest that appropriate funds be made
available for those who are unable to
pay for the immunization.
Also, approved the following rec-
ommendation:
VOL. 87— NUMBER 4 APRIL 1990
331
That the Medical Society of New Jer-
sey request the Department of En-
vironmental Protection to provide
educational programs for physicians,
through the Academy of Medicine of
New Jersey, pertaining to medical
waste disposal.
Task Force on AIDS . . . Dis-
cussed the following recommen-
dation and asked Mr. Maressa to
contact the chairman of the Task
Force on AIDS to discuss the con-
cerns:
That the Board of Trustees confer with
the Attorney General regarding clari-
fication of the physician’s responsi-
bility and possible liability as outlined
in the law.
Committee on Physicians’
Health . . . Directed that concerns
about the AMA and its impaired
physicians program be expressed
in a communication to the AMA
and to Dr. Karl Franzoni for con-
tinued monitoring in his capacity
as chairman of the New Jersey del-
egation and chairman of the AMA
Reference Committee “F.”
New Business . . .
(1) Medicare Reimbursement on
Unassigned Claims . . . Directed
the AMA Delegation to develop an
appropriate resolution for in-
troduction at the AMA Annual
Meeting expressing objection to
the new requirement (that physi-
cians complete and mail the reim-
bursement form to Pennsylvania
Blue Shield and notify the patient
that the physician has complied
with the requirement).
(2) Hospital Medical Staff Sec-
tion (HMSS) . . . Noted the fol-
lowing items: caucus expenses;
nominating committee report with
the following for consideration:
chairman, George T. Hare, MD,
vice-chairman, Angelo S. Agro,
MD, secretary, Carlo Porcaro,
MD, member-at-large, J. Jerome
Cohen, MD, and alternate del-
egate, Robert L. Wegryn, MD;
selection of George T. Hare, MD,
as HMSS representative to the
MSNJ Board of Trustees; copies of
model medical staff bylaws avail-
ability and requested William P.
Isele, Esquire, to prepare model
bylaws for New Jersey; and appli-
cability of assured option law to
eligible tissue donors and request
of state attorney general to review
concerns.
Correspondence . . . Noted the
following: letter from Leah Z.
Ziskin, MD, acting commissioner
of health stating the Department is
reviewing the Society’s recommen-
dations from our Task Force on the
Shortage of Nurses and Technical
Personnel and a letter from the
president of the Hudson County
Medical Society to the president of
the State Board of Medical Exam-
iners requesting that physician as-
sistants not be permitted to prac-
tice in the state. □
HUMDNJ NOTES
The annual University Day pro-
gram of the University of Medicine
and Dentistry of New Jersey
(UMDNJ) was a great success this
year, setting the right tone for the
new year and, indeed, the new dec-
ade. This year’s program was high-
lighted by the awarding of
UMDNJ’s University Medal for
Distinguished Leadership to Gov-
ernor Jim Florio (represented by
New Jersey Secretary of State
Joan Haberle); the presentation of
excellence awards to UMDNJ em-
ployees; and my State of the Uni-
versity address.
UMDNJ’s seven-year $520 mil-
lion statewide capital development
plan — the Facilities Master Plan —
was the focus of the address. The
plan, which spans 1990 through
1997, encompasses new and ex-
panded health care, education,
and research facilities at
UMDNJ’s campuses in northern,
central, and southern New Jersey.
Highlights of the Facilities Mas-
ter Plan include:
• Camden/Stratford. Southern
New Jersey projects totalling ap-
proximately $65 million include:
Camden — Renovation of the
Education and Research Building
for the UMDNJ-Robert Wood
Johnson Medical School to con-
solidate faculty offices and give
faculty better access to research
space; and acquisition of a build-
ing to replace the existing Emer-
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
332
NEW JERSEY MEDICINE
gency Medical Services facility.
Stratford — Continued develop-
ment of the campus of the
UMDNJ-School of Osteopathic
Medicine, including an Academic
Center; an addition to the Educa-
tion and Research Building
(already under construction); and
UMDNJ-Community Mental
Health Center; student housing;
and renovation of the Kennedy
Professional Center for adminis-
trative offices and research labora-
tories.
• Piscataway/New Bruns-
wick. Central New Jersey projects
totalling approximately $165
million include:
Piscataway — A research tower
for the UMDNJ-Robert Wood
Johnson Medical School; a facility
(under construction) for the En-
vironmental and Occupational
Health Sciences Institute (oper-
ated jointly by UMDNJ and
Rutgers University); student hous-
ing; an administration building for
UMDNJ-Robert Wood Johnson
Medical School; expansion of the
UMDNJ-Community Mental
Health Center to provide emer-
gency and other support services;
a professional building to house
staff and services of the UMDNJ-
Community Mental Health
Center, now located in nearby
Dunellen; and a children’s residen-
tial treatment unit at the
UMDNJ-Community Mental
Health Center.
New Brunswick — A medical of-
fice building and parking deck for
UMDNJ-Robert Wood Johnson
Medical School.
• Newark. Newark campus
projects totalling approximately
$290 million include: renovation of
the 65 Bergen Street building (for-
merly Martland Medical Center)
to house the UMDNJ-School of
Health-Related Professions and
University administrative func-
tions; a facility for the joint New
Jersey Cancer Center/Center for
Molecular Medicine and Im-
munology; expansion of the Medi-
cal Science Building to provide
more research laboratories,
classrooms, and faculty offices for
UMDNJ-New Jersey Medical
School and UMDNJ-New Jersey
Dental School; a “helideck” for
UMDNJ-University Hospital’s
trauma helicopter, part of the
state’s Jemstar air-rescue emerg-
ency medical service; expansion
and renovation of the UMDNJ-
Smith Library; an off-campus
Family Health Care Center of
UMDNJ-University Hospital; and
an outpatient facility for the
UMDNJ-Community Mental
Health Center.
Financing for the Facilities Mas-
ter Plan will come from a variety
of sources, including UMDNJ’s
capital and operating budgets; the
state’s Jobs, Education & Com-
petitiveness Bond Act of 1988; the
sale of University bonds; and fund-
raising. Completion of projects will
depend upon UMDNJ’s ability to
continue to attract federal and pri-
vate grants and to maximize rev-
enues from its health care services.
The University has identified
$30 million in support for the plan,
leaving about $490 million to be
funded. Of that amount, about $74
million is not included in the Uni-
versity’s seven-year plan, based on
current financial projections; sev-
eral projects will be funded in the
succeeding seven years.
In the past fiscal year,
UMDNJ’s external funding sup-
port, which includes all grant and
contract awards, reached $61.7
million, an 18.1 percent increase
over the previous year. An average
annual increase of 20 percent will
bring UMDNJ’s outside funding to
$200 million by 1996, a level com-
mensurate with the top-ranking
health-sciences schools in the na-
tion. □ Stanley S. Bergen, Jr, MD
■■IMSNJ AUXILIARY**
Health programs, workshops,
cultural events, and charity fund-
raisers dominated recent county
calendars. Camden County spon-
sored an “Adolescent Health
Education Day” at Haddonfield
Memorial High School and stu-
dents from the various county high
schools were invited to the all-
morning session. Twenty-nine
health professionals spoke on
topics ranging from the physical to
the emotional aspects of good
health. This is the second con-
secutive year that Camden County
has presented the successful pro-
gram.
In Gloucester County, auxiliary
members developed a program
focusing on the health needs of
senior citizens. An excellent film,
“Wellness After Sixty,” was pur-
chased and auxiliary members who
are geriatric and mental health
nurses wrote instructional/dis-
cussion guides to accompany the
film. The complete package will
serve as a continuing education
program for the county’s numerous
senior citizen groups and nursing
homes.
Passaic County designed a
GEMS Program (Good Emergency
Mothers Program) originally for-
mulated by the AMA Auxiliary.
They now are in the process of find-
ing people who can speak Spanish,
Turkish, Arabic, or Asian, to talk
to different groups of babysitters
and parents.
Salem County earned a certifi-
cate from the American Cancer So-
ciety for participating in the Great
American Smokeout; auxiliary
members made small packets of
sugarless candies to help the
smokers trying to quit and dis-
tributed educational materials
about smoking to physicians’ of-
fices.
Many counties also held work-
shops and programs for the benefit
of their members. “Medical Con-
cerns After 25 Years” was the topic
of a lecture presented by a gyne-
cologist in Atlantic County. In
Camden County, a certified public
accountant spoke on “Financial
Planning,” and in Mercer County,
an attorney/assemblywoman spoke
on “Women in Law and Politics.”
Gloucester County presented a
VOL. 87— NUMBER 4 APRIL 1990
333
program on “Landscaping with
Perennials.”
Thousands of dollars for nursing
scholarships and other auxiliary
charities also were realized. Cam-
den County raised over $5,000 on
their “Annual Theatre Trip to New
York.” Gloucester County netted
$2,200 on an “Art Show and Auc-
tion.” Burlington County hosted a
prosperous “Progressive Dinner”
and Mercer County held a benefit
at the Off-Broad Street Theatre.
Passaic’s breakfast fundraiser and
art tour through the Brooklyn Mu-
seum and Botanical Gardens
sparked great interest while Salem
County’s well-attended “Mistletoe
Ball” enhanced the county’s
Gertrud Jonas Nursing Scholar-
ship Fund.
In addition, Mercer County col-
lected food and raised $1,100 for
the Physicians’ Health Program.
The Union County Auxiliary came
to the aid of organizations and
churches that, needed food and
clothing for the homeless. They
also collected canned goods and
household items for the Battered
Women’s Shelter.
Finally, almost every county
auxiliary in the state held func-
tions to earn money for the Ameri-
can Medical Association Educa-
tion and Research Foundation
(AMA-ERF). Holiday sharing
cards, boutiques, bazaars, raffles,
and luncheons brought in
thousands of dollars for the Aux-
iliary’s most significant nation-
wide charity.
Praising the New Jersey Aux-
iliary’s philanthropic endeavors
and volunteer efforts, Lonnie R.
Bristow, MD, AMA-ERF presi-
dent, reminded auxiliary members
at the September 1989 Confluence
in Chicago, “When you become in-
volved you clearly enhance the
image of the medical profession in
every possible way. Every time you
get your name before the public,
some of the luster rubs off on the
AMA. We love you for it, and we
thank you for it.” □ Marion H.
Geib
SMSSAMNJ REPORT mSHS
The Academy of Medicine of
New Jersey, the Medical Society of
New Jersey, and the New Jersey
State Department of Health,
Division of AIDS Prevention and
Control will present three major
symposia on “Identification and
Management of Asymptomatic
HIV-Infected Persons in New Jer-
sey,” to be held in May at the fol-
lowing locations: Tuesday, May 1,
1990 — 8:30 A.M., Sheraton Newark
Airport; Wednesday, May 2,
1990 — 8:30 A.M., Cherry Hill Inn;
and Wednesday, May 9, 1990 —
8:30 A.M., Sands Hotel & Casino,
Atlantic City. Richard Dixon, MD,
program chairperson, has an-
nounced that Henry Mazur, MD,
chief of critical care medicine at
the National Institutes of Health,
will be the keynote speaker for the
May 1 and 2 events. Additional
participants are Drs. James
Oleske, John Sensakovic, and Alan
Lin-Greenberg.
On Saturday, March 31, 1990,
the Academy of Medicine spon-
sored a major symposium, “Nonin-
vasive Vascular Imaging in the
1990s,” at the Ramada Renais-
sance Hotel, East Brunswick. The
New Jersey Institute of Ultrasound
in Medicine and the Vascular So-
ciety of New Jersey cosponsored
the event. Participants were shown
how to identify normal and ab-
normal patterns of vascular dis-
ease by noninvasive techniques. Il-
lustrative examples were presented
by the faculty on slide and video
formats. Emphasis was on color
doppler applications and high-res-
olution real-time ultrasonography.
The final segment of the sym-
posium offered a preview of the
next generation of noninvasive
vascular imaging with magnetic
resonance angiography. Dr. M.
Stanley Kron was program chair-
man.
On April 1, 1990, the Academy
added the American College of
Cardiology (ACC), NJ Chapter to
The History of
Women Physicians
in New Jersey
Copies available
for $6.50 per issue
Send check or money order to:
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
334
NEW JERSEY MEDICINE
our list of societies. ACC is a pres-
tigious, national specialty society
that has decided to develop a
chapter component. The first
president is Dr. John Gregory, and
ACC anticipates a membership of
over 700 in its first year of oper-
ation.
The New Jersey Physicians Golf
Association Executive Committee
met, and tournament dates and lo-
cations are being scheduled for the
1990 season. Further information
will be disseminated in the near
future; however, we are pleased to
announce that Metedeconk Na-
tional in Jackson will be one of the
sites. Membership information is
available by contacting Lisa
Swartek at the Academy’s Ex-
ecutive Offices. □ Frederick B.
Cohen, MD, President
■■PLACEMENT FILEHH
The following physicians have
written to the Executive Offices of
MSNJ seeking information on op-
portunities for practice in New Jer-
sey. The information listed below
has been supplied by the physi-
cians. If you are interested in any
further information concerning
these physicians, we suggest you
make inquiries directly to them.
GASTROENTEROLOGY
Eric Avezzano, MD, 2510 B.S. Walter
Reed Dr., Arlington, VA 22206. SUNY-
Stony Brook 1985. Board certified
(IM); board eligible (GI). Group, part-
nership, solo. Available July 1990.
GENERAL PRACTICE
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Also, internal medicine. Available.
Randi Silverbrook, DO, 3024 Wistar
Ct., Bensalem, PA 19020. College of
Osteopathic Medicine 1985. Partner-
ship or group. July 1990.
INTERNAL MEDICINE
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Also, general practice. Available.
David D. Gross, MD, 1045 Liberty St.,
Apt. 1, Trenton, NJ 08611. St.
George’s University (Grenada) 1987.
Board eligible. Available August 1990.
Suresh Reddy, MD, 3301 Cobblestone
Circ., #6, Waterloo, IA 50703.
Kakatiya (India) 1980. Board certified.
Board eligible (GASTRO). Group,
partnership, solo. Available.
NUCLEAR MEDICINE
Robert W. Cifers, MD, 26 Somers
Ave., Seaville, NJ 08230. Ohio State
1983. Board eligible. Available.
PATHOLOGY
Judith Vople, MD, 106 Orlando Blvd.,
Toms River, NJ 08757. UMDNJ 1985.
Board eligible. Group or hospital-
based. Available July 1990.
PHYSICAL MEDICINE
Robert B. Thorne, MD, 112 Woodside
Ave., Trenton, NJ 08618. Rutgers 1980.
Board certified. Part time or full time.
Available.
1990 ANNUAL MEETING
Saturday, May 5, 1990
3:30 p.m. Board of Trustees’ Meeting
7:00 p.m. Officers' Cocktail Reception and Dinner
Sunday, May 6, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
10:00 a.m. Educational Programs
11:00 a.m. Exhibits Open
1 :00 p.m. House of Delegates
3:30 p.m. Reference Committee Meetings
Monday, May 7, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates (Election)
12:00 noon Golden Merit Award Ceremony and Reception
1:00 p.m. Professional Liability Program (MIIENJ)
2:45 p.m. Reference Committee Meetings
5:00 p.m. JEMPAC Political Forum
5:45 p.m. JEMPAC Wine and Cheese Reception
Tuesday, May 8, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates
1:30 p.m. House of Delegates
2:00 p.m. Exhibits Close
6:30 p.m. Inaugural Reception and Dinner
Wednesday, May 9, 1990
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. General Session
1 .00 p.m. Board of Trustees’ Meeting
VOL. 87— NUMBER 4 APRIL 1990
335
THE YOUNG PHYSICIANS COMMITTEE
of the
MEDICAL SOCIETY OF NEW JERSEY
and
THE YOUNG LAWYERS DIVISION
of the
NEW JERSEY STATE BAR ASSOCIATION
PRESENT
THE FIRST ANNUAL
HOMELESS AWARENESS
CONFERENCE
The objective of this program is to heighten public
awareness of the homelessness crisis and to train
professionals, educators, lawyers, physicians and
social service providers, in the areas of care re-
quired by homeless individuals so that these pro-
fessionals may more effectively provide services
for the homeless in their area especially on a
professional and pro bono basis.
DATE: Friday, May 11, 1990
LOCATION: New Jersey Law Center
One Constitution Square
New Brunswick, NJ 08901-1500
TIME: 9:00-9:30
9:30-10:15
10:30-12:00
12:15-1:30
2:00-3:30
3:45-4:45
Registration
Opening session
Workshops
Lunch
Workshops
Open Legislative Forum
COST: $20.00
For additional information contact
Ron Rouse at MSNJ (609) 896-1766
Elizabeth General Medical Center Foundation
and
Ross Laboratories
present
The First Annual
IRVING R. FOX MEMORIAL LECTURE
ON PEDIATRIC AMBULATORY CARE
Guest Speaker
BENJAMIN M. SPOOK, M.D.
“Raising Children: Now and Then”
SUNDAY, APRIL 29, 1990
10:30 A.M.
Elizabeth General Medical Center
Education/Conference Center
925 East Jersey Street
Elizabeth, New Jersey 07201
A buffet brunch will be served prior to the presentation.
No admission charge. Limited seating is available ONLY
by calling 201-558-8479
AIDSline
~ The Academy of Medicine of NJ,
The Medical Society of NJ &
The New Jersey State Department of Health
Division of AIDS Prevention & Control
present
Identification and Management of
Asymptomatic HIV-Infected Persons in
New Jersey
Tuesday, May 1, 1990, 8:30 AM. - 1:45 P.M. at the
Sheraton Newark Airport in Elizabeth
or
Wednesday. May, 2, 1990, 8:30 AM. - 1:45 P.M. at the
Cherry Hill Inn in Cherry Hill
or
Wednesday, May 9*. 1990, 8:30 - 1 1:30 AM. the Medical
Society of New Jersey's Annual Meeting at the Sands
Hotel & Casino in Atlantic City
Participants will be able to develop an effective case-
management plan for early HIV infection that can be
implemented in their offices or clinics and will learn
about new treatment approaches under study.
Richard E. Dixon, MD, Course Chairman
Lunch is included on May 1st and 2nd. Fee $15.
• No preregistration or fee required.
Call AMNJ, 609-896-0486 for further information.
336
BHH
NEW JERSEY MEDICINE
JUNE 16
10th ANNUAL ADVANCES
IN GASTROENTEROLOGY
BALLY’S PARK PLACE
ATLANTIC CITY, NEW |ERSEY
For further
information, contact:
Registration Manager
SLACK Incorporated
6900 Grove Road
Thorofare, N.J. 08086
609-848-1000
Acupuncture & Electro-Therapeutics
in Clinical Practice
New York State Boards of Medicine & Dentistry
25-hour accredited seminar & workshop on latest theories
and techniques of manual & electro-acupuncture, TENS &
simple non-invasive diagnostic methods (including
cardio-vascular, neuromuscular, central nervous systems &
” B i- Digital O-Ring Test"), applicable towards 300-hour
requirement for certification to practice acupuncture, will be
given periodically for licensed clinicians (with or without
prior training) on 3-day weekends (Fri-Sun) of March
23-25, May 11-13, June 15-17, July 13-15, Sept. 21-23,
and Dec. 14-16, 1990, at Milford Plaza Hotel, 45th St. &
8th Ave., or 1 10 Fulton St. (12th fl.), New York City.
The 6th Annual International Symposium on
Acupuncture & Klectro-Therapeutics will be held at
Columbia University, School of International Affairs, 420
W. 118th St., N.Y. City, during October 25-28, 1990.
These meetings are co-sponsored by the International
College of Acupuncture & Electro-Therapeutics & its official
journal, Acupuncture & Electro-Therapeutics Research. The
International Journal (.published by Pergamon Press &
indexed in 15 major indexing periodicals, including Index
Medicus), Heart Disease Res. Foundn, N Y Pain Center of
Long Island College Hospital (a teaching hospital of
SUNY-Health Science Center at Brooklyn); Electrical
Engineering Dept., Manhattan College; Nordic Medical
Acupuncture Society (Scandinavia); Schmerz Therapeutische
(Colloquium (West Germany); Japan Bi-Digital O-Ring Test
Assn; etc. The meetings are also eligible for AMA CME Cat.
I credit (about 40 credit-hours for the Symposium).
For information on meetings or submission or
presentation of papers, contact Symposium Chairman Y.
Omura, M.D., Sc.D., 800 Riverside Drive (8-1) New York,
NY 10032 Tel: (212) 781-6262 (10am to 10pm 7 days a
week) or (212) 928-0658, Dr. Shinnick (212) 727-9674, or
Bro. Michael Losco (212) 920-0162.
The Advanced
Management
Program
for Clinicians
New York University
Being a doctor simply wasn’t enough for Richard Sadovsky. He
also wanted to be a teacher, an administrator, and a leader.
“Medical school prepared me to be a doctor”, he says. “It
didn’t prepare me to be a teacher and administrator. To expand
my vision of the health services profession, to understand how
the health system is organized and financed, and, finally, to
participate in the process, I needed to develop strong manage-
ment skills.
“I also needed to strengthen my knowledge of marketing,
financial analysis, quality assurance, strategic planning, and
management information systems.”
Dr. Sadovsky is now the activist he wants to be. Only recent-
ly, for example, he helped set up an advisory council on the care
of the older adult.
“I now have the skills to work inside the system and to change
and improve it.”
Find out what the Advanced Management Program for Clini-
cians can do for you. Most participants take classes on a part-
time basis once or twice a week in the evenings or on Saturdays.
Some paid residencies, internships, and partial tuition fellow-
ships are available.
For more information, contact us at (212) 998-7460 during
business hours.
The Robert F. Wagner
Graduate School of Public Service
New York University
4 Washington Square North
New York, NY 10003
(212) 998-7460
VOL. 87— NUMBER 4 APRIL 1990
337
ALLERGY
May
7- Immunology and the Visual
8 System
8 A.M.-5 P.M. — Bally’s Grand
Hotel, Atlantic City
(UMDNJ)
ANESTHESIOLOGY
May
15 Meeting
6-9 P.M. — Ramada Inn, Clark
(New Jersey State Society of
Anesthesiologists)
DERMATOLOGY
May
16 Robert Wood Johnson
Medical School
Dermatological Conferences
6-9 P.M. — Rutgers Community
Health Plan, US #1,
New Brunswick
(UMDNJ)
24 Update on Superficial Fungal
Infections
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
INFECTIOUS DISEASE
May
1 Identification and Management
of Asymptomatic HIV-Infected
Persons in New Jersey
8:30 A M. -1:45 P.M. — Sheraton
Newark Airport, Elizabeth
(AMNJ, MSNJ, and NJDOH)
2 Identification and Management
of Asymptomatic HIV-Infected
Persons in New Jersey
8:30 A. M. -1:45 P.M. — Cherry Hill
Inn, Cherry Hill
(AMNJ, MSNJ and NJDOH)
2 Lyme Disease
10:30-11:30 A. M. — St. Mary’s
Hospital, Passaic
(AMNJ and NJDOH)
9 Proper Use of Antibiotics
10:30-11:30 A. M. — St. Mary’s
Hospital, Passaic
(AMNJ and NJDOH)
9 Identification and Management
of Asymptomatic HIV-Infected
Persons in New Jersey
8:30-11:30 A.M. — Sands Hotel &
Casino, Atlantic City
(AMNJ, MSNJ, and NJDOH)
22 Clinical Management of HIV
Infection
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH )
.30 Lyme Disease
10:30-11:30 A.M.— Christ
Hospital, Jersey City
(AMNJ and NJDOH)
MEDICINE
May
1 Aspiration Syndrome in the
Mentally Retarded
1-2 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
1 Fourth Annual Internal
8 Medicine Update and
15 Board Review
22 5:30-7:30 P.M. — Cooper Hospital,
29 Camden
( Cooper Hospital/UMDNJ)
2 Medical Lecture Series
9 10:30-11:30 A.M. —Christ
16 Hospital, Jersey City
23 ( Christ Hospital)
2 Internal Medicine Review
9 Course
16 4-7 P.M. — University Hospital,
23 New Brunswick
(AMNJ and UMDNJ)
3 Computers in Medicine
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
3 Liver Transplantation
11 A.M. — St. Joseph’s Hospital
and Medical Center, Paterson
(St. Joseph’s Hospital and
Medical Center)
4- Combined Annual Meeting
5 Cherry Hill Inn, Cherry Hill
(New Jersey Society of
Pathologists and PA Association
of Clinical Pathologists)
4 Continuing Medical
11 Education Program
18 12 Noon-1 P.M. — South Jersey
25 Hospital System, Bridgeton
(South Jersey Hospital System)
6- MSNJ Annual Meeting
9 Sands Hotel Casino and County
Club, Atlantic City
(MSNJ)
8 Renal Biopsy Conference
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
9 Medical Malpractice: Criminal
Law and Tort Issues
10:30-11:30 A.M. —Christ
Hospital, Jersev City
(AMNJ)
10 Diabetes-Related
Kidney Disease
1:30-2:30 P.M. — Vineland
Developmental Center, Vineland
(AMNJ and NJDOH)
10 Update on Geriatric Medicine
24 4:30-6:30 P.M. — Cooper Hospital,
Camden
( Cooper Hospital/UMDNJ)
1 1 New Laboratory Diagnostic
Tests
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
14 Retinopathy
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
15 Volume Homeostatis in
Pregnancy
6:30-9:30 P.M. — Overlook
Hospital, Summit
(AMNJ)
16 Nutritional Assessment
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
16 Dilemmas of Dying
10:30-11:30 A.M. —Christ
Hospital. Jersey City
(AMNJ)
17 Continuing Medical Education
12 Noon-1 P.M. — Somerset
Medical Center, Somerville
(Somerset Medical Center)
338
NEW JERSEY MEDICINE
Pointing the
way to more
CME credit.
Earn more CME credit
with Postgraduate
Medicine’s new and
improved CME Program
sponsored by the
Interstate Postgraduate
Medical Association.
More CME credits for
less money ($10.00).
Practical questions
covering the most im-
portant points from
each article— not just
one symposium article.
Now, more than ever,
you’ll want to read
every issue of
Postgraduate Medicine
from cover to cover!
4530 W 77th Street
Minneapolis, MN 55435
(612)835-3222
June 11-15, 1990
Update Your Medicine 1990.
Cornell University Medical College and Association of
Practicing Physicians of the New York Hospital. 36 Vi
hour Category I credit (42 if optional workshops are
taken). One week review of all subspecialties of internal
medicine. Nine major two-hour symposia, six hour re-
view lectures, and Medical Grand Rounds. Four work-
shops will be given for practical problems and manage-
ment techniques. Optional workshop sessions on
Breast/Pelvic and Male Genitorectal examinations.
Held at the New York Hospital-Cornell, 1300 York Av-
enue at 69th Street, New York, Information: Office of
CME, 212-746-4752, or write Room D-115. Dr. Lila
Wallis is Course Director.
o
o
10th ANNUAL
EMERGENCY MEDICINE
SEMINAR
MONDAY-FRIDAY
JUNE 11-15, 1990
This seminar provides registrants with a rational
and systematic approach to clinical decision making
in the Emergency Department. It is designed for
Emergency Medicine Practitioners and for those
sub-specializing in Emergency Medicine.
A comprehensive syllabus complements the course.
Accreditation: 29.5 AMA Category I Credit Hours
Tuition: $650
Call or Write: (212) 340-5295
NYU Post Graduate Medical School
550 First Avenue, NY, NY 10016
NJM4/90
VOL. 87— NUMBER 4 APRIL 1990
339
18 Retinopathy
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
18 Rheumatoid Arthritis: Etiology
and Pathogenesis
12:15-1:15 P.M. — Kennedy
Memorial Hospital, Stratford
(UMDNJ and Kennedy Memorial
Hospital)
19 Morbidity and Mortality
26 Conference
8:30-10 A.M. — New Jersey
Medical School, Newark
(UMDNJ)
23 Functional Assessment
of the Elderly
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
24 Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center)
June
1 Prevention of Lower Extremity
Amputations
9-10 A.M. — St. Francis Medical
Center, Trenton
(AMNJ and NJDOH)
1 Continuing Medical
8 Education Program
15 12 Noon-1 P.M. — South Jersey
22 Hospital System, Bridgeton
29 ( South Jersey Hospital System)
4- 1 1th Annual Comprehensive
22 Course in Occupational Health
8:30 A.M. -5 P.M. — Robert Wood
Johnson Medical School,
Piscataway
(UMDNJ)
5- Annual Meetings
6 Trump Plaza Hotel and Casino,
Atlantic City
(NJ Gastroenterological Society
and NJ Society for
Gastroenterological Endoscopy)
5 Fourth Annual Internal
12 Medicine Board Review
19 5:30-7:30 P.M. — Cooper Hospital,
26 Camden
( Cooper Hospital/UMDNJ)
6 Adrenal Disease
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
6 Medical Lecture Series
13 10:30-1 1:30 A.M. —Christ
Hospital, Jersey City
( Christ Hospital)
7 Erythropoietin
11 A.M. — St. Joseph’s Hospital
and Medical Center, Paterson
(St. Joseph ’s Hospital and
Medical Center)
12 Renal Biopsy Conference
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
13 Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
13 Parkinson’s Disease
8:30 A.M. -5 P.M. — Robert Wood
Johnson Medical School,
Piscataway
(UMDNJ)
13 Parkinsonism
10:30-11:30 A.M— Christ
Hospital, Jersey City
(AMNJ)
14 Aspiration Syndrome in the
Mentally Retarded
1-2 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
15 Diabetes in Pregnancy
9-10 A.M. — St. Francis
Medical Center,
Trenton
(AMNJ and NJDOH)
20 Medical Aspects of Nutrition —
Anorexia and Weight Loss
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
21 Continuing Medical
Education Series
12 Noon-1 P.M. — Somerset
Medical Center, Somerville
(Somerset Medical Center)
OBSTETRICS/GYNECOLOGY
June
8- Annual Meeting
9 Trump Plaza Hotel Casino,
Atlantic City
(New Jersey Obstetrical and
Gynecological Society)
16- Risk Management
17 in Obstetrics
and Gynecology
8 A.M. -5 P.M. — The Diplomate
Hotel, Atlantic City
(UMDNJ)
OCCUPATIONAL MEDICINE
June
6 Occupational Asthma in
New Jersey
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
ONCOLOGY
May
9 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
1 1 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
16 First Annual Joint Meeting
6:30-9:30 P.M. — The Manor,
West Orange
( Head and Neck Oncology and
Radiation Oncology Sections —
AMNJ)
24 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
June
8 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
( Wallkill Valley Hospital Center)
13 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of
Salem County, Salem
(Memorial Hospital of Salem
County)
28 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
PEDIATRICS
May
3 Pediatric Grand Rounds
10 8:30-9:30 A.M. — Robert Wood
17 Johnson Medical School, MEB,
24 102, New Brunswick
(UMDNJ)
4 Sudden Infant Death
12 Noon- 1 P.M. — South Jersey
Hospital System, Bridgeton
(South Jersey Hospital System)
PSYCHIATRY
May
1 Anxiety and Stress
8:30-10 A.M. — Elizabeth General
Medical Center, Elizabeth
(Elizabeth General Medical
Center)
3 Case Seminars To Improve
17 Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
340
NEW JERSEY MEDICINE
1
PHILADELPHIA HEART INSTI
of Presbyterian Medical Center
I Cardiology
Update
designed for the physician and provides an intensive
survey of the current status of clitiical cardiology. . .
Wednesday, May 2, 1990
Surgery For Acquired Heart Disease
Moderator
Ami E. Iskandrian, M.D.
3:00-3:30 What is the optimal timing for aortic or mitral valve
replacement? W. Clark Hargrove, III, M.D
3:30-4:00 When is coronary artery obstruction
significant? William P. Santamore, PhD.
4:00-5:00 Case presentations — Patients who need valve replacement
and coronary artery bypass surgery Stafford Smith, M.D
Panel discussion
Terry Langer, M.D., Thach N. Nguyen, M.D.,
William ]. Untereker, M.D., Gary J. Vigilante, M.D
■ Case Presentations and Panel Discussions
■ CME Credits*
■ No Registration Fee
■ Call for Reservation 2 1 5-662-862 7
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
The Philadelphia Heart Institute at Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
“The University of Pennsylvania School of Medicine is accredited by the Accreditation Council for Continuing Medical
Education to sponsor continuing medical education for physicians. The University of Pennsylvania School of Medicine
designates this Continuing Medical Education activity for 2 credit hours per session' in Category 1 of the Physician's
Recognition Award of the American Medical Association."
V.
VOL. 87— NUMBER 4 APRIL 1990
341
6 Psychiatric Aspects of AIDS 17
2-3 P.M. — John E. Runnells
Hospital of
Union County,
Berkeley Heights
(AMNJ)
7 Case Seminars To Improve 24
3 PICA Syndrome and Psychiatry
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
8 Grand Rounds
15 8:30-10 A. M— Dept, of
22 Psychiatry, Elizabeth General
29 Hospital, Elizabeth
(Elizabeth General Hospital)
10 The Use of Video in Psychiatric
Treatment
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
23 High Anxiety
All day — Carrier Foundation,
Belle Mead
( Carrier Foundation)
24 Narcolepsy
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
31 The Borderline Personality in
the Hospital Setting
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
June
5 Psychiatry Grand Rounds
12 8:30-10 A. M. — Elizabeth General
19 Medical Center, Elizabeth
26 (Elizabeth General Medical
Center)
Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
7 Brain, Biology, and Behavior
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
14 Maintenance ECT: When
and How?
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
21 Effects of Brain Injury on
Behavior and Emotions
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
RADIOLOGY
May
14 Ultrasound
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
1990 Scientific Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of
New Jersey-Diagnostic Section,
AMNJ)
Visiting Professor Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
( Saint Barnabas Medical Center)
SURGERY AND ITS SPECIALTIES
May
1 Weekly Vascular Case
8 Conference
15 7:30-8:30 A. M. — Robert Wood
22 Johnson Medical School, MEB,
29 108B, New Brunswick
(UMDNJ)
6 Surgical Treatment of
Cardiothoracic Disease
10-11 A.M. — New Jersey Medical
School, MSB, 506B, Newark
(UMDNJ)
10- Fourth Annual Meeting
13 Sheraton Boston Hotel and
Towers, Boston
(Eastern Vascular Society)
26 Englewood Surgical Society
Lecture Series
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society)
26 Morbidity and Mortality
Conference
8:30-10 A.M. — New Jersey
Medical School, MSB, 506B,
Newark
(UMDNJ)
June
5 Weekly Vascular Case
12 Conference
19 7:30-8:30 A.M. — Robert Wood
26 Johnson Medical School, MEB,
108B, New' Brunswick
(UMDNJ)
8 Diagnosis and Surgical
Management of Esophageal
Reflux and Hiatus Hernia
1-2 P.M. —North Princeton
Developmental Center, Princeton
(AMNJ)
20 High-Risk Surgery
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
UROLOGY
May
4 Urology Grand Rounds
11 New Jersey Medical School,
18 MSB, C600, Newark
25 (UMDNJ)
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
342
NEW JERSEY MEDICINE
Hahnemann University
Department of Medicine
WEDNESDAYS GRAND ROUNDS
8:30 A.M.-9:30 A.M.
April-May 1990
APRIL 1990
April 4, 1990
CARDIAC ELECTROPHYSIOLOGY:
EVOLVING DIAGNOSTIC AND
THERAPEUTIC MODALITIES
John D. Fisher, M.D.
Professor of Medicine
Director, Cardiac Arrhythmia Service
Acting Director, Division of Cardiology
Montefiore Medical Center
New York, NY
April 11, 1990
MEDICAL MANAGEMENT OF GALLSTONE
DISEASE
Hans Fromm, M.D.
Professor of Medicine
Director, Division of Gastroenterology
The George Washington University
Washington, DC
April 18, 1990
ENDOCRINOLOGY AND METABOLISM:
RECENT ADVANCES
Leslie I. Rose, M.D.
Professor of Medicine
Director, Division of Endocrinology and
Metabolism
Hahnemann University
Jeffrey L. Miller, M.D.
Associate Professor of Medicine
Division of Endocrinology and Metabolism
Hahnemann University
APRIL 25, 1990
Infectious Diseases: Treatment of
Difficulty and Opportunistic Fungal
Infections
GUEST FACULTY
William E. Dismukes, M.D.
Professor and Vice-Chairman
Department of Medicine
Univ. of Alabama School of Medicine
David J. Drutz, M.D.
Adjunct Professor of Medicine
Univ. of Pennsylvania School of Medicine
Adjunct Professor of Microbiology &
Immunology
Temple University Medical School
Thomas J. Walsh, M.D.
National Cancer Institute
National Institutes of Health
April 25, 1990
PROSTHETIC VALVE ENDOCARDITIS
William E. Dismukes, M.D.
Professor & Vice Chairman for
Educational Programs
Department of Medicine
University of Alabama
Birmingham, AL
MAY 1990
May 2, 1990
VENOUS THROMBOEMBOLIC
DISORDERS: UPDATE 1990
John C. Hoak, M.D.
Director, Division of Blood Diseases and
Resources
National Heart, Lung and Blood Institute
National Institutes of Health
Bethesda, MD
May 9, 1990
IMMUNE MECHANISMS:
BREAKTHROUGHS IN
IMMUNOSUPPRESSION
George H. Hitchings, Jr., Ph.D., D.Sc.
Nobel Prize Winner 1988 in Medicine and
Physiology
Duke University
Durham, NC
Adjunct Professor of Pharmacology
University of North Carolina
Chapel Hill, NC
Scientist Emeritus
Burroughs Wellcome Co.
WEDNESDAYS
MEDICAL SEMINAR SERIES
8:30 A.M. -3:00 P.M.
HAHNEMANN UNIVERSITY FACULTY
Emily A. Blumberg, M.D.
Abdolghader Molavi, M.D. (Course
Director)
Craig A. Wood, M.D.
MAY 9, 1990
The Age of Immunosuppressive Therapy
and Organ Transplantation
GUEST FACULTY
George H. Hitchings, Jr., Ph.D., D.Sc.
Nobel Laureate, 1988, Medicine and
Physiology
Adjunct Professor of Pharmacology &
Experimental Medicine
Duke University
Terry Strom, M.D.
Professor of Medicine
Harvard Medical School
Director of Clinical Immunology
Beth Israel Hospital
Boston, MA
May 16, 1990
INFECTIOUS DISEASES: NEWEST
ADVANCES
Abdolghader Molavi, M.D.
Associate Professor of Medicine &
Surgery
Director, Division of Infectious Diseases
Hahnemann University
May 23, 1990
“NEW FASHION" CLINICAL PATHOLOGIC
CONFERENCE
Kenneth Cohen, M.D.
Associate Professor of Medicine
Director, Internal Medicine Residency
Program
Hahnemann University
May 30, 1990
“OLD FASHION" CLINICAL PATHOLOGIC
CONFERENCE
Eugene Coodley, M.D.
Professor of Medicine
Univeresity of California, Irvine
Director of Geriatric Medicine
Longbfedch VA Hospital
Longbeach, CA
Adjunct Professor of Pharmacology
University of North Carolina
Scientist Emeritus, Burroughs Wellcome
& Co.
Terry Strom, M.D.
Professor of Medicine
Harvard Medical School
Director of Clinical Immunology
Beth Israel Hospital
President
American Society of Immunology
HAHNEMANN UNIVERSITY FACULTY
Joseph H. Brezin, M.D.
Isadore Brodsky, M.D.
Robert Chvala, M.D.
Farokh Samini, M.D.
Allan B. Schwartz, M.D. (Course Director)
Presented by:
We wish to acknowledge educational support from
William S. Frankl, M.D.
Location:
Professor of Medicine and Chairman
Classroom C (Alumni Hall)
Bristol Meyers-Squibb
Department of Medicine
2nd Floor— College Bldg.
Burroughs Wellcome & Co.
Allan B Schwartz, M.D.
Hahnemann University
Professor of Medicine and
15th Street Entrance
Director, Continuing Medical Education
15th and Vine Streets
Department of Medicine
Philadelphia, PA
Approved for CME credits through the Office of Continuing Education, Hahnemann University
For further information: (215) 448-8263
VOL. 87— NUMBER 4 APRIL 1990
343
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344
■i
IN MEMORIAM
Robert J. Andrus. At the un-
timely age of 35, Robert John An-
drus died on December 30, 1989. A
psychiatrist with a private practice
in East Rutherford, Dr. Andrus
was a member of our Bergen Coun-
ty component. Born in Jersey City,
Dr. Andrus earned his medical
degree from UMDNJ-New Jersey
Medical School, Newark, in 1980;
he received his New Jersey medical
license the following year. During
his short career, Dr. Andrus was
affiliated with Bergen Pines Coun-
ty Hospital, Paramus. Dr. Andrus
was a member of the American
Psychiatric Association and of the
AMA, and was a diplomate of the
American Board of Psychiatry.
Laurence A. Donahue. After a
lengthy illness, neurosurgeon
Laurence Austin Donahue, MD, a
member of our Monmouth County
component, died on January 1,
1990. Born in 1926 in Warren,
Ohio, Dr. Donahue was awarded
his medical degree from Marquette
University Medical School, Wis-
consin, in 1954. After graduation,
he served an internship at St.
Elizabeth’s Hospital, Ohio, and a
residency at the Cleveland Clinic,
Ohio. In 1960, Dr. Donahue re-
ceived his license to practice in
New Jersey. In addition to mem-
bership in the state society, Dr.
Donahue was a member of the
American Medical Association and
a fellow of the Congress of Neu-
rological Surgeons. During his ca-
reer, Dr. Donahue was affiliated
with Monmouth Medical Center,
Long Branch, and Riverview Hos-
pital, Red Bank.
Mary V. Elkin. At the age of 64,
Mary Versakos Elkin, MD, died on
December 31, 1989. A dermatolo-
gist, Dr. Elkin was on the staff of
Hackensack Medical Center since
1961, and w'as an attending physi-
cian at Bergen Pines County Hos-
pital, Paramus. Born in 1925 in
Passaic, Dr. Elkin was awarded
her medical degree from the Uni-
versity of Zurich Medical School,
Switzerland, in 1956. She com-
pleted an internship at Beth-El
Hospital, New York, in 1957, and
in 1960 received her license to
practice in New Jersey. Dr. Elkin
was an active member of our
Bergen County component and
was a fellow of the Academy of
Medicine of New Jersey.
Donald Green. Former market-
ing director for Hoffmann-La
Roche, Inc., Donald Green, MD,
died on January 7, 1990. After re-
tiring, Dr. Green served as a con-
sultant to numerous New Jersey
pharmaceutical companies. Born
in 1926 in Orange, Dr. Green
earned his medical degree from
New York University College of
Medicine in 1950. He served an in-
ternship at Newark Beth Israel
Medical Center in 1951, and com-
pleted a residency in internal
medicine at the VA Hospital in
Houston, Texas. In 1971, Dr.
Green graduated with a marketing
degree from the New School of
Social Research, New York. Dr.
Green was a member of our Essex
County component and of the
American Medical Association.
During the Korean conflict, Dr.
Green served in the United States
Air Force as a captain and also as
the chief of medicine at Andrews
Air Force Base in Washington, DC.
William F. Jones. An emeritus
member of our Somerset County
component, William Felix Jones,
MD, died on December 28, 1989.
Born in 1914 in Pennsylvania, Dr.
Jones earned his medical degree
from Temple University Medical
School, Pennsylvania, in 1939; the
following year, he received his
license to practice medicine in
New Jersey. He served an in-
ternship at Atlantic City Hospital,
Atlantic City, and a residency at
Somerset Hospital, Somerville. A
general practitioner, Dr. Jones was
affiliated with Somerset Medical
Center during his lengthy career.
Dr. Jones was a fellow of the
American Academy of Family
Physicians and a member of the
American Medical Association.
After his retirement, Dr. Jones re-
located to Winston-Salem, North
Carolina. During World War II,
Dr. Jones served in the medical
corps as a captain.
Marion F. Kaletkowski. A
past-president of the Passaic
County Medical Society, Marion
Francis Kaletkowski, MD, died on
December 20, 1989. Born in 1914 in
Lodi, Dr. Kaletkowski earned his
medical degree from Georgetown
University Medical School, Wash-
ington, DC, in 1939. He completed
a residency in anesthesiology at St.
Vincent’s Hospital, New York, and
an internship at St. Mary’s Hospi-
tal, Passaic. Dr. Kaletkowski re-
ceived his license to practice in
New Jersey in 1940. Dr. Kaletkow-
ski served as medical director and
anesthesiologist at St. Mary’s Hos-
pital, for the next 40 years. During
his lengthy career, Dr. Kaletkow-
ski was the president of the Passaic
VOL. 87— NUMBER 4 APRIL 1990
345
County Mental Health Associa-
tion, a diplomate of the American
Board of Anesthesiology, and a
member of our Passaic County
component, of the American So-
ciety of Anesthesiologists, and of
the American Medical Association.
He also served as public health of-
ficer for Clifton for over 25 years.
During World War II, Dr. Kalet-
kowski was chief of anesthesia and
operating rooms with the 61st Gen-
eral Hospital in England.
Joseph J. Kohn. Word has been
received of the death of Joseph J.
Kohn, MD, on November 20, 1989.
Born in Philadelphia, Pennsyl-
vania, Dr. Kohn earned his medi-
cal degree from the University of
Michigan Medical School in 1935;
he received his license to practice
in New Jersey the following year.
An ophthalmologist with St. Fran-
cis Medical Center, Trenton, Dr.
Kohn was a member of our Mercer
County component and a fellow of
the American Academy of Oph-
thalmologists and Otolaryngol-
ogists. From 1942 to 1946, Dr.
Kohn was a captain in the United
States Air Force.
Vincenzo R. Onorato. Pornpton
Lakes physician, Vincenzo Raf-
faele Onorato, MD, died on De-
cember 27, 1989. Born in 1910 in
Montclair, Dr. Onorato earned his
medical degree from Royal Univer-
sity of Naples, Italy, in 1939. He
served his residency at All Souls
Hospital, Morristown, in the early
1940s. From 1942 to 1946. Dr. On-
orato served the United States
Army Medical Corps, attaining the
rank of major; he received two
Bronze Stars, the American Cam-
paign Medal, the Victory Medal,
the Asiatic/Pacific Campaign
Medal, and Meritorious Service
Unit Plaque. Affiliated with
Chilton Memorial Hospital,
Pornpton Plains, St. Vincent’s
Hospital, Montclair, and St.
Joseph’s Hospital and Medical
Center, Paterson, Dr. Onorato was
a member of our Passaic County
component and of the American
Medical Association. In 1989, Dr.
Onorato was honored with MSNJ’s
Golden Merit Award for 50 years of
medical service.
James H. Thorpe. At the un-
timely age of 61, James Hancock
Thorpe, MD, died on December
24, 1989, of a heart attack. Born in
1928 in Orange, Dr. Thorpe earned
his medical degree from Columbia
University College of Physicians
and Surgeons, New York, in 1953.
He served a residency and fellow-
ship at IM Strong Memorial Hos-
pital, Rochester, New York. From
1965 to 1973, Dr. Thorpe was senior
military consultant in medicine to
the USAF surgeon general, rising
to the rank of colonel; he was
awarded the USAF Commenda-
tion Medal. Dr. Thorpe was a
member of our Mercer County
component before relocating to
California in 1989, and was a mem-
ber of the Publication Committee
for NE W JERSE Y MEDICINE. In
1989, he coedited a special issue on
continuing medical education for
the state journal. Dr. Thorpe was
a member of the American Medi-
cal Association, of the American
Society of Internal Medicine, and
of the American Psychosomatic
Society; he was a fellow of the
American College of Physicians
and of the American College of
Gastroenterology. Dr. Thorpe
served as medical director for
Lower Bucks Hospital, Bristol,
Pennsylvania.
John J. Torppey. A specialist in
diabetes, John Joseph Torppey,
MD, died on January 9, 1990. Dr.
Torppey had practiced privately
since 1937 in Newark. He was
awarded his medical degree from
Georgetown School of Medicine,
Washington, DC, in 1934, and
served an internship at Essex
County Hospital, Belleville, and
City Hospital, Newark. During his
illustrious career, Dr. Torppey was
affiliated with Saint James Hospi-
tal, Presbyterian Hospital, both in
Newark; Essex County Hospital
Center; and East Orange General
Hospital. A retired member of our
Essex County component, and of
the American Medical Association,
Dr. Torppey held various positions
in the medical community: board
member of the Essex County Tu-
berculosis League, the New Jersey
Appeal Board Selective Service
System, and the Advisory Board of
Essex County Hospital; past-presi-
dent of the New Jersey Diabetes
Association, the Essex County
Medical Society, the Essex County
Services for the Chronic 111, and
the Essex County Blood Bank;
vice-chairman of the subcommit-
tee for the aging, Newark; medical
director of the Community Coordi-
nated Home Care Program; con-
sulting physician for All Souls
Hospital, Morristown; chief of the
Diabetic Clinic at Presbyterian
Hospital; and member of the
boards of trustees of the Essex
County Services for the Chronical-
ly 111 and of the New Jersey Dia-
betes Association. During World
War II, Dr. Torppey was chief of
medical services on the Army hos-
pital ship, Blanche F. Sigman. He
retired to Toms River in 1978.
Louis A. Trevisan, Jr. After a
brief illness, Louis Alphonse Trevi-
san, Jr, MD, died on December 22,
1989. Born in 1924 in Newark, Dr.
Trevisan received his medical
degree from Georgetown Univer-
sity Medical School, Washington,
DC, in 1947 and was awarded his
New Jersey license in 1948. An
anesthesiologist. Dr. Trevisan was
affiliated with Clara Maass Medi-
cal Center, Belleville; Columbus
Hospital, Saint Michael’s Medical
Center, and Presbyterian Hospital,
all in Newark; and Shore Mem-
orial Hospital, Somers Point. Dr.
Trevisan was a member of our
Essex County component and of
the American Medical Association.
From 1949 to 1951, Dr. Trevisan
served in the United States Navy,
and also was a veteran of the
Korean War.
346
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NEW JERSEY MEDICINE
PH0P1SSI0NAL
LIABILITY
U.S.TORT SYSTEM The cost of the U.S. tort system, including claims payments, adminis-
COSTS INCREASE trative costs, and attorney’s fees, is increasing rapidly, far outdistancing
these costs in other countries, says a recent report prepared by the
Tillinghast division of Towers, Perrin, Forster & Crosby Inc.
These costs have risen from $7.9 billion in 1965 to $117 billion in 1987
and now represent 2.6 percent of the gross national product — triple the
percentage of the GNP spent in 12 other industrialized nations.
Only in one other country — Switzerland — did tort system costs exceed
more than 0.6 percent of the GNP and there the percentage was 0.8
percent. Here is the percentage of GNP in 1986 in some other nations
studied: Australia, 0.3; Denmark, 0.4; Japan, 0.4; Spain, 0.4; Italy, 0.5;
West Germany, 0.5; Austria, 0.6; Canada, 0.6; and France, 0.6. Figures
were not available for 1986 but in 1985 Belgium and the United Kingdom
each spent 0.5 percent of the GNP for their tort systems.
“Whereas tort costs in other countries have remained stable over the
last 20 years, our costs have escalated,” said Robert Sturgis of Till-
inghast’s property/casualty division.
The report suggested one possible reason other countries spend less on
tort systems is that they have more extensive welfare systems that
presumably take care of victims and reduce the need to sue.
A copy of the report, “Tort Cost Trends: An International Perspective,”
is available on request from Towers, Perrin, Forster & Crosby Inc.,
Marketing Services, 100 Summit Lake Drive, Valhalla, NY 10595. (Re-
printed with permission from Medical Liability Monitor, Winnetka, IL
60093. Volume 14, Number 12, December 21, 1989)
HOSPITAL FUNCTIONS Two surgeons were not entitled to a preliminary injunction against a
WITH CLOSED STAFF hospital that decided to function with a closed staff for performing heart
bypass operations, a California appellate court ruled. The two board
certified surgeons had been members of the hospital’s medical staff for
more than ten years. They performed a majority of the cardiac ex-
tracorporeal bypass surgeries performed at the hospital. The physicians
experienced a very low mortality rate, but the overall mortality rate of
bypass operations at the hospital was 8.4 percent, an unacceptably high
rate for the hospital.
A committee determined that the problems identified at the hospital
resulted from the fact that a substantial number of independent surgeons
performed bypass surgery at the hospital and other hospitals spread over
a wide geographical area. The hospital decided to drastically change its
heart surgery program from the open staffing structure it had operated
under for a number of years to a closed, exclusive program directed by
a highly qualified surgeon under contract with the hospital and working
with a fairly constant team of supportive personnel. The hospital felt
this approach would foster uniformity, teamwork, and a lower mortality
rate.
/OL. 87— NUMBER 5 MAY 1990
365
PROFESSIONAL LIABILITY
The two surgeons refused to be in charge of the new program because
they did not wish to confine their practices to the hospital and did not
want responsibility for quality control. After the hospital notified all of
the bypass surgeons on its staff that after July 19, 1988, they would not
be able to perform independent bypass surgery at the hospital, the two
surgeons filed suit.
Affirming the trial court’s denial of a preliminary injunction, the ap-
pellate court said that the hospital’s decision to function with a closed
rather than an open system did not interfere with any vested interest
of the staff physicians. The hospital’s interest in improving patient care
and reducing mortality rates outweighed potential adverse economic
impact on the physicians. Hospitals had a right to make rational man-
agement decisions, even when exercise of that right might prove adverse
to the interest of specific individual practitioners, the court said. Red-
ding v. St. Francis Medical Center, 255 Cal. Rptr. 806 (Cal. Ct. of App.,
Feb. 28, 1989). (Reprinted with permission from The Citation, American
Medical Association, Volume 60, January 15, 1990)
COUPLE SUES IVF A husband and wife, in their attempt to obtain possession of their
PROGRAM cryopreserved human pre-zygote, have a valid cause of action against
the in vitro fertilization (IVF) program that stored the pre-zygote, a
federal trial court in Virginia ruled. The husband (a physician) and his
wife entered the IVF program at the Medical College of Hampton Roads,
in Norfolk, Virginia, in 1986. At that time, the couple lived in the
northeast. During the course of the treatment, they moved to California.
The couple underwent the in vitro fertilization attempt on four separate
occasions. None of these attempts resulted in pregnancy. Prior to the
fourth attempt, the couple signed a cryopreservation agreement for
cryopreservation of pre-zygotes. The agreement outlined the procedure
and the couple’s rights to the frozen pre-zygote(s). The IVF program
physician then removed and fertilized six eggs, creating six embryos. The
physician transferred five embryos to the mother’s uterus and the sixth
was cryogenically preserved pursuant to the procedures outlined in the
agreement.
Approximately one year after freezing the sixth embryo, the couple
sought to have the pre-zygote transferred from the IVF program in
Virginia to an IVF program in Los Angeles, California, for an in vitro
fertilization attempt. The physician at the Virginia IVF program refused
to allow the transfer. The couple sued the Virginia IVF program for
breach of contract, detinue, and violations of the 1st, 4th, 9th, and 14th
amendments. The IVF program filed a motion to dismiss.
In support of their breach of contract claim, the couple claimed the
Virginia IVF program’s continued dominion and control over the frozen
pre-zygote is contrary to the language of the cryopreservation agreement.
The agreement provided:
1. The couple may discontinue participation at any time and that the
program would not continue to store the pre-zygotes after they withdrew.
2. The couple has the principal responsibility to decide on the disposi-
tion of the pre-zygotes.
3. If the couple divorced, legal ownership of pre-zygotes must be
determined in a property settlement.
4. If the couple decides in the future to cease attempts to initiate
pregnancy, they may choose one of three options for their frozen pre-
zygotes: donate to another couple (whose identity will remain unknown),
donate for approved research investigation, or thaw but not allow to
undergo further development.
366
NEW JERSEY MEDICINE
PROFESSIONAL LIABILITY
The Virginia IVF program and its physicians contended that the couple’s
proprietary rights were limited to the three options enumerated in the
contract because there is no established protocol for the inter-institu-
tional transfer of pre-zygotes.
The court found that the three options apply only if the couple no longer
wishes to attempt pregnancy. Moreover, the court held that the
cryopreservation agreement created a bailment relationship which im-
poses on the bailee (the IVF program), when the purpose of the bailment
has terminated, “an absolute obligation to return the subject matter of
the bailment to the bailor” (the couple). The cryopreservation agreement
indicated that the IVF program and its physicians recognized the limits
of their possessory interest by recognizing the couple’s proprietary rights
in the pre-zygote, i.e. the reference in the agreement to the couple’s
principal responsibility to determine the disposition of the frozen pre-
zygotes; the requirement that in the event of divorce, legal ownership
must be set forth in a property settlement; and the repeated references
to “our [the couple’s] pre-zygote.”
The court found valid the couple’s claim of detinue (a cause of action
for the recovery of specific personal property unjustly detained) based
on much of the reasoning used in the finding of a bailment.
The couple based their claim of constitutional violations on the theory
that the IVF program’s exercise of dominion and control over the pre-
zygote violated their constitutional right to reproductive privacy. The
court found that the Medical College of Hampton Roads was a gov-
ernmental entity but had a great deal of autonomy over its internal
operations and the discharge of its statutory duties and powers. There-
fore, according to the court, the IVF program of the Medical College was
not entitled to 11th amendment immunity (state immunity from suits
by residents of another state).
Thus, the court denied the IVF program’s motion to dismiss any of the
couple’s claims, and the suit will proceed.
COMMENT This court held that frozen pre-zygotes are the personal property of the
couple. It is unclear why the IVF program refused the couple’s request
for the inter-institutional transfer of the pre-zygote. While the terms of
the agreement appeared to cover all possibilities, e.g. divorce, it did not
anticipate the possibility of a request for an inter-institutional transfer.
Because it is not possible to foresee every possibility, legal theories, such
as bailment, developed over centuries, provide a consistent framework
for settling disputes.
Commentators fear that cases such as this are likely to increase in the
future. There are over 4,000 frozen pre-zygotes in the United States
{Time, July 24, 1989), but state laws often do not address the questions
to be resolved or do not do so realistically. For instance, one problem
could arise if a statute defines a pre-zygote as a person. Does the pre-
zygote have the right to inherit? Also, a problem could arise if the couple
donates the pre-zygote to another couple. Do they have to go through
adoption proceedings?
Many ethicists believe a couple’s claim to use of its frozen pre-zygote
has a basis in law and common sense. Most ethicists agree that the
couple’s right is not absolute; the couple should not be able to authorize
inappropriate experimentation. (Terrie A. Rymer, JD, staff attorney,
Health Law Division, AMA. Reprinted with permission from The Cita-
tion, American Medical Association, Volume 60, January 1, 1990) □
VOL. 87— NUMBER 5 MAY 1990
367
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BE ALL YOU CAN BE.
kk It’s uniquely sensitive, flexible, allowing you the
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my Army Reserve pay plus my stipend pays me up to
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resident at Episcopal Hospital in Philadelphia with plans to
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were obvious and the flexibility during my training made
it unbeatable. I have been able to postpone my Reserve
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Honduras, to experience medicine in the broader
sense would not exist were I not in the Army Reserve. It's
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If you are a resident specializing in anesthesiology,
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thoracic, plastic, orthopedic, peripheral/vascular, and
neurosurgery, and would like more information on the
Army Reserve Specialized Training Assistance Program
(STRAP], call 1-800-USA-ARMY.
MSNJ
NEWSLETTER
KUDOS FOR NEW JERSEY MEDICINE has been awarded the Special Prize in the
NEW JERSEY MEDICINE Sandoz Medical Journalism Competition for 1990. The award for
outstanding appearance and editorial qualities for a state medical as-
sociation publication, recognizes the unique importance of state pro-
fessional journals. “Readers of medical and pharmaceutical publications
receive stacks of journals, magazines, and other mail,” said Dr. Craig
Burrell, president of Sandoz. “It is a tribute to the editorial staffs of
these low-budget local publications that they are so avidly read by many
readers who rank them with major national media.” This is MSNJ’s fifth
award in the past ten years for publishing a consistently high-quality
journal.
LEGAL What should you do when an investigator from the State Board of
NOTES Medical Examiners or some other government agency appears at your
door? This question has been the topic of a great deal of legal activity.
The situation ordinarily arises when an investigator, badge in hand, asks
to speak to a physician about a particular case or issue. The physician,
who does not want to be rude or antagonistic, invites the investigator
into the office, and finds that he is the target of what could well be a
serious action. Before the meeting ends, the investigator hands the physi-
cian a subpoena, demanding he either immediately turn over certain
records, or appear personally, in Newark or some other place, to deliver
the records in the future.
Most physicians when confronted with this situation talk to the in-
vestigator, permit inspection of their facilities, and turn over their rec-
ords. Yet, in most cases this is absolutely the wrong thing to do. Not
only may the physician provide more information than necessary, he
unwittingly may provide information that could result in disciplinary
action. If the investigator is from an agency other than the State Board
of Medical Examiners, the physician also may breach patient confiden-
tiality— even though the investigator has a subpoena.
Many years ago, the courts in the state held that no one could be required
to provide immediate testimony or immediately turn over records. As
a result, the “forthwith” subpoena was ruled unconstitutional. In an
effort to get around that court ruling, the State Board of Medical Exam-
iners and others now issue subpoenas that give the physician the choice
of either turning over documents immediately, or personally delivering
the materials at a future date. Do not be intimidated by the subpoena.
You need not personally deliver the documents, regardless of what the
subpoena states. You do have time to consult with an attorney before
providing any information — written or oral. Also, you generally do not
have to permit an inspection of your offices.
If investigators arrive at your door, accept any documents they hand you,
and politely advise them that you will contact them after speaking with
your attorney.
On a related note, many physicians have been receiving demands from
VOL. 87— NUMBER 5 MAY 1990
369
MSNJ NEWSLETTER
attorneys for patient records. Be aware that without a recently signed
patient authorization (no more than six months old) that specifically
authorizes the release of the records in your possession, you are
prohibited, by law, from turning over such documents. The fact that the
request may be accompanied by a subpoena makes no difference. In
these circumstances, you should advise the attorney requesting the
records that you require an appropriately signed, original patient release.
In addition, you are entitled to a reasonable fee for the cost of copying
any records requested. A reasonable fee depends upon the circumstances,
but fees within the range of $.50 to $1.50 per page for photocopying and
$2.00 to $10.00 for copies of x-rays are not unusual, depending upon the
amount of work and expense involved. Ordinarily you have 30 days to
provide these materials to the patient or patient’s representative, absent
some emergent situation. Do not be intimidated by an attorney who
threatens to subpoena your testimony if you do not turn over records
without charge. There is no good faith basis for him to do so and, if the
attorney attempts to issue such a subpoena, you should immediately
contact the Medical Society of New Jersey. Many counties have recipro-
cal agreements with bar associations and the offending attorney will be
advised of the impropriety of his efforts.
In short, do not talk to investigators. Tell them that you will contact
them after speaking to your attorney. Do not give them access to your
offices; do not show them any documents. Rather, contact your health
care attorney immediately to understand your rights, and provide infor-
mation only after a full analysis of your position. If you are approached
by a representative of the State Board of Medical Examiners and belong
to the Prepaid Legal Services Program endorsed by the Society, call Kern
Augustine Conroy & Isele; after hours, call the 24-hour emergency
number for assistance. If not, call the health care lawyer of your choice.
□ Kern Augustine Conroy & Isele, P.A.
CATASTROPHIC Applications are available for the Catastrophic Illness in Children Relief
ILLNESS IN CHILDREN Fund Program. Created by legislation to provide financial assistance to
families whose children have experienced serious illnesses or conditions
that have not been covered fully by insurance or other program benefits,
program applications are available by calling 609/292-0600. To receive
assistance, families must meet three criteria: medical expenses not cov-
ered by insurance must exceed 30 percent of a family’s income, if income
is less than $100,000 or 40 percent if the income is over $100,000;
the child must be 17 years of age or younger; and the parents or guardians
must be resident(s) of New Jersey for at least six months prior to date
of the application.
POISON INFORMATION The New Jersey Poison Information and Education System (NJPIES)
£ EDUCATION SYSTEM ^as been serving professionals for over eight years. In addition to
answering calls concerning suspected poisonings, NJPIES answers drug
information requests from physicians and other health care personnel.
For information about adverse drug reactions, drug interactions, or drug
dosing for patients with renal failure or undergoing dialysis, call
NJPIES; also call for assistance in identifying a drug. NJPIES is avail-
able 24 hours a day, seven days a week; nonemergency calls can be
answered, Monday to Friday, from 8 A.M. to 5 P.M. Place emergency calls
immediately. The number to call is 1/800/962-1253.
RETIREMENT THROUGH Due to tremendous interest, the seminar sponsored by the Medical
SUCCESSFUL MONEY Society of New Jersey and the AMA Investment Advisers, Inc. will be
MANAGEMENT ^eld a£ain- “Retirement Planning Through Successful Money Manage-
ment” will be held at MSNJ headquarters on June 13 and June 14, 1990.
370
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
The program, given in its entirety on both days, runs from 9:30 A.M. to
4:30 P.M. Lunch will be provided as well as refreshments during the
morning and afternoon breaks. You will learn how to set your personal
financial goals, plan for retirement, lower your taxes, and develop a
financial plan. In addition, the seminar will cover a variety of investment
alternatives such as stocks, bonds, mutual funds, real estate, and much
more. You can register for the seminar by calling the Department of
Medical and Insurance Affairs at MSNJ headquarters, 609/896-1766.
The registration deadline is June 1, 1990; space is limited. Members and
spouses are invited to attend.
AIDS POLICY REPORT The AMA is taking a stand in favor of mandatory contact tracing
through state health agencies for all persons infected with HIV. The
statement came in the AMA’s policy update report on AIDS. A national
study should also be done to find out the degree of HIV infection in the
LTnited States, the AMA said. This is the only way to monitor the course
of AIDS, to plan treatment, and to evaluate prevention and care, as-
serted the AMA. The report also confirmed the AMA’s determination
to study the cost of care for patients in each stage of the disease; to
support funding for research and treatment; to advance HIV training
for primary care MDs and specialists; to encourage physicians to educate
patients about HIV; and to endorse insurance indemnification of stu-
dents and residents infected with HIV on the job.
WHAT ARE YOU SAYING The question, “Is quality CME — at acceptable cost — really accessible
ABOUT CME? you?” received a 78 percent yes answer and a 22 percent no answer,
and the question, “Has CME caused you to change the way you provide
treatment to patients in the last year?” received a 65 percent yes answer
and a 35 percent no answer.
HEALTH CARE COSTS If your company’s health insurance bills are going haywire, you are not
alone. The average cost per employee now is $3,000 and rising 20 to 30
percent a year and the cost is greater for small firms with big claims.
There is only one way to get a handle on costs, so say specialists in
employee health insurance programs. Get involved, manage them, and
keep close watch. They eat profits. Companies no longer can be passive
payers.
REGIONAL MEDICAL Region 1 of the Regional Medical Library (RML) Program will be sepa-
LIBRARY NETWORK rated into new regions in 1991, and the name of the program will be
changed to reflect its national scope. These changes will be made to focus
attention on fundamental changes in the mission and goals of the Na-
tional Library of Medicine’s programs to insure that health professionals
have timely and convenient access to needed biomedical information.
Region 1 will consist of New York, New Jersey, Pennsylvania, Delaware,
and the Commonwealth of Puerto Rico.
GIBBS TO HEAD Governor Florio has named Albert J. Gibbs to head the State Depart-
HUMAN SERVICES mer,t °f Human Services. Mr. Gibbs comes from the Washington State
Department of Social and Human Services and also served as deputy
commissioner of human services under former Governor Brendan Byrne.
DOCTOR OF THE YEAR Ralph Fioretti, MD, has been given the “Doctor of the Year” award by
the New Jersey Academy of Family Physicians. Fioretti has maintained
a family practice in Rochelle Park for over 40 years. He serves on the
executive committee of the Board of Governors at Hackensack Medical
Center and also is medical director of a 300-bed nursing home complex.
Dr. Fioretti is a past-president of the Medical Society of New Jersey and
VOL. 87— NUMBER 5 MAY 1990
371
MSNJ NEWSLETTER
of the Bergen County Medical Society. Dr. Fioretti represents MSNJ
as a delegate to the American Medical Association.
WASTE DISPOSAL Approximately 60 New Jersey hospitals have agreed to participate in a
NJHA group purchasing contract for the removal of medical waste. The
two-year contract was awarded to Medical and Hazardous Waste Man-
agement Corp. of New York.
UNIVERSAL HEALTH Representatives of Citizen Action, the state’s largest citizen coalition
with 65 affiliated labor and community groups, called for a federal
universal health care system to better serve the health care needs of the
nation. Victor DeLuca, director of the Ironbound Community Corp.,
asked that all members of the state’s congressional delegation cosponsor
the “Health For All” resolution introduced by Rep. Henry Waxman (D-
California). The resolution proposes a national health care system.
HEALTH CARE Assemblymen John V. Kelly (R-Essex) and Patrick J. Roma (R-Bergen)
INSURANCE solicited Governor Florio to establish an emergency commission to cope
COMMISSION ^ew Jersey’s worsening health care insurance problems. The legis-
lators want the commission to review the Uncompensated Care Trust
Fund, the hospital rate reconciliation system, and the availability of
individual health insurance, among other matters. The Assemblymen
were prompted to call for the emergency commission by increased public
awareness of an impending crisis in health insurance.
ICD-9-CM NJDOH has received ICD-9-CM coding appeals from several hospitals.
CODING APPEALS The aPPeals stated that the October 1987 changes in ICD-9-CM coding
mandated by the federal government and mapped into New Jersey
Grouper Version 2 DRGs by the Department, caused reduced hospital
reimbursement due to case migrations among DRGs. The migrations
identified by the appeal were as follows: Group I — DRGs 115-118 migrat-
ing to DRGs 442-443 (Pacemakers); Group II — DRGs 154-156 migrating
to DRGs 182-184 (Endoscopies); Group III — DRGs 87-89 migrating to
DRG 101 (Respiratory).
The Department’s recommendation for each of these areas is as follows:
Group I — no adjustment will be recommended for this grouping of DRGs.
The Department believes that the revision to the procedure code could
not have caused a change in revenue for these hospitals. Group II —
hospitals may elect to recode and resubmit all of its 1988 records within
this DRG grouping in accordance with coding definitions. The hospital
must notify the Department of its intent to recode by April 16, 1990,
and all documentation must be submitted by May 15, 1990. The eco-
nomic impact requirement of the lower of $10,000 or 0.1 percent DPC
revenue must be met for an adjustment to proceed. Group III — no adjust-
ment will be recommended for this grouping of DRGs. Although the
changes in mapping of the respiratory codes could result in revenue
changes, the differences were not large and may be offset by other gains.
HUMAN SERVICES The Department of Human Services made a request to the Office of
DEPT. REQUESTS Management and Budget at the end of the Kean administration for a
$300 million funding increase. Human Services requested $2.5 billion for
the new fiscal year, an increase of $300 million. Nearly half of the
increase is attributable to projected rises in Medicaid program costs.
Based on the department’s estimate, the state’s share of Medicaid fund-
ing will increase from $865 million to $1 billion. Human Services also
is asking for $28 million more for the 2,500 patients in the seven state
psychiatric facilities, and $36 million more for the Division of Youth and
Family Services.
372
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
NEWARK TO RECEIVE Under a Senate emergency AIDS assistance proposal introduced by
PROPOSED AIDS FUNDS Senator Edward M. Kennedy (D-Massachusetts), Newark would be
eligible for $6.5 million in federal aid. The bill would provide a total
of $600 million for AIDS work nationwide, including $300 million of
emergency aid to cities with over 2,000 AIDS cases, such as Newark,
which has 3,339 cases. The emergency funds would go to health care
facilities to service low-income AIDS cases and to community-based
outpatient health and support services.
MEDICARE ASC
RATES ISSUED
The final notice of Medicare payment rates and revision of the Am-
bulatory Surgical Center (ASC) payment rate methodology was pub-
lished in the Federal Register on February 8, 1990, after almost a two-
year delay over implementation of the rule change. The final notice sets
forth the revised payment rates based on a refined methodology using
recent survey data from participating ASCs. The refinements include
the establishment of eight payment groups rather than the six proposed
groups and the four current groups. Only two of these eight groups
contain cataract procedures. The new methodology incorporates into the
rate computation the use of the HCFA wage index and the payment of
$200 for an intraocular lens (IOL) inserted during cataract surgery. The
rates are effective on March 12, 1990, rather than July 1, 1988, the
original implementation deadline. The rates before wage adjustment are
as follows:
Group 1 $247
Group 2 $332
Group 3 $381
Group 4 $469
Group 5 $535
Group 6 (includes IOL fee) $705
Group 7 $743
Group 8 (includes IOL fee) $814
The new methodology is based on revised data including a reassessment
and reassignment of certain procedures to higher groupings when ap-
propriate. Use of the revised ASC rates will be incorporated into the
blend of payments methodology for ambulatory surgical procedures per-
formed in a hospital outpatient department.
MEDICAID BUREAU HCFA Administrator Gail Wilensky has recommended the creation of
PROPOSED a Medicaid Bureau within the Health Care Financing Administration.
This policy initiative is her first since being confirmed to her adminis-
trator position and is consistent with her goal of heightening Medicaid’s
status and visibility during her term. The plan would consolidate and
merge 190 full-time Medicaid personnel currently spread throughout
HCFA. The proposed bureau plan is being discussed with HHS Secretary
Louis W. Sullivan, MD, and is expected to be approved. The director
of the new bureau would report directly to Wilensky.
MEDICARE LAB TESTS According to a recent report from Health and Human Services, Office
COST TWICE AS MUCH °f Inspector General, physicians pay almost half as much as Medi-
care pays for clinical laboratory tests. The report found that physicians
pay a lower amount for an entire group of tests while Medicare Part B
pays for each test individually. The report recommended HCFA imple-
ment measures to eliminate the rate discrepancy including development
of Medicare policies and procedures for group test rates.
BLUES MANAGED According to a recent report by InterStudy of Excelsior, Minnesota, six
CARE PLANS nationally managed care firms account for the largest market share of
VOL. 87— NUMBER 5 MAY 1990
373
MSNJ NEWSLETTER
managed care enrollment of 27.8 million as of January 1989. Of the 27.8
million enrollees, 14.3 million or more than one-half were enrolled in
managed care plans of Blue Cross and Blue Shield Association of Chi-
cago, Illinois.
PHYSICIANS’ SALARIES According to an American Medical Association report, physicians’ 1988
INCREASE ne*- ‘ncome increased approximately 11 percent from 1987 to a median
of $120,000. The highest net income of all physician specialties is the
surgeon’s at approximately $208,000. Since 1985, the physicians’ median
net income increased approximately 26 percent. The -range of physician
average net income annual growth from 1981 to 1988 was 5.1 percent
for general/family practice to 8.2 percent 'for pathology and 8.8 percent
for surgery. The report indicated that the 1988 average annual physician
salary increase outstripped the 7.5 percent increase in physician prices
measured by the Consumer Price Index.
SURGERY ADMISSION According to the SMG Marketing Group in Chicago, admissions to U.S.
PATE IS UP hospitals in 1989 saw the percentage of surgical admissions rise to 67.5
percent as compared to 60.1 percent in 1985.
A White House Domestic Policy Council has been established to study
ways of reducing malpractice costs. At a recent talk at Johns Hopkins
University, President Bush somewhat chastised physicians for practicing
“defensive medicine,” although agreeing that a way must be found to
reduce rising costs. The study is being led by Stuart Gerson, assistant
attorney general of the Justice Department and includes Health and
Human Services Secretary Louis Sullivan, MD, on the Council.
OUTPATIENT CATARACT 'The Outpatient Ophthalmic Surgery Society of San Diego filed suit
SURGERY against the Department of Health and Human Services in the U.S.
District Court in Washington, DC, challenging the payment rates for
outpatient cataract surgery performed on Medicare patients. The So-
ciety claims that the payment rateswiolate the Medicare statute because
they do not cover the cost of providing such surgery in the ambulatory
surgery centers that are being reimbursed.
HEALTH CARE SHOWS U.S. Healthcare Inc., the for-profit Pennsylvania-based HMO, reported
HIGH PROFIT a 12 percent increase in membership and a 35 percent increase in rev-
enues for 1989. Its net income of $28 million for 1989 was almost 700
percent above its 1988 income. The Company’s membership rose to over
one million last year when its HMOs in New Jersey, Connecticut, Dela-
ware, Maine, New York, and Pennsylvania were taken into account.
DISSATISFIED WITH A study performed in the Chicago area^ by Midwest Business Group on
HMO PLANS Health, found that current HMO enrollees want to switch health plans,
they are less satisfied with their plan than non-HMO participants, and
would not recommend a HMO to anyone. Of the nine enrollee satisfac-
tion criteria, in only one of the criteria did HMOs win — protection
against the cost of illness. Non-HMO plans scored almost 36 percent
higher on the choice/continuity of care criteria, and almost 15 percent
higher on the overall perceived quality criteria.
ANTI-FRAUD According to Carl Schramm-, president of Health Insurance Association
of America (HIAA), the driving force behind anti-fraud activities is cost
containment. HIAA indicated that health insurers could save an esti-
mated $350 million by adopting a 'Cost ^containment program, and that
15 health insurers saved approximately $45 million last year because of
these efforts. A survey of 110 health insurers found that in 1989 approx-
imately 43 percent of the fraud cases involved services not being
STUDY OF
MALPRACTICE COSTS
374
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
rendered, while approximately 33 percent involved improper dates or
diagnoses.
PHYSICIAN REFERRALS According to the American Medical Association, overall physical refer-
rals to their own facility dropped about 1 percent from 1988 to 1989.
The most significant decline occurred with general and family practi-
tioners whose self-referral percentage went from about 10 percent to
about 5 percent. The study also noted that physicians earning $150,000
or more are making more self-referrals while those under $150,000 are
making less self-referrals. Most physicians only have an investment in
one facility, and started with no more than an initial investment of
$10,000.
NOVELLO CONFIRMED Antonio Novello, MD, a pediatrician and AIDS expert, has been con-
firmed by the Senate as Surgeon General. Novello was a deputy director
of the National Institute of Child Health and Human Development.
PROTECT MEDICARE House and Senate leaders continue to criticize the Bush Adminis-
tration’s proposed $5.6 billion spending reductions for 1991. Senate
•Finance Committee Chairman Lloyd Bentsen (D-Texas) referred to the
magnitude of the proposed cuts as astounding. Bentsen urged HHS
Secretary Louis W. Sullivan, MD, who testified during the Finance
Committee’s February 28 hearing, to work with members of the Commit-
tee to determine how Medicare, spending can be reduced without “a
major dislocation” of services needed by beneficiaries.
PENSION PLAN Two hospital chains, Hospital Corporation of America (HCA) and Hu-
TERM I NATIONS mana> improperly withheld $28 million in Medicare payments from gains
realized when they terminated, their pension plans. The Office of Inspec-
tor General (OIG) alleges that HCA adjusted its reversion based on their
interpretation of the regulations while Humana amortized its reversion
over an eight-year period without any adjustment .for Medicare.
MEDICAID AND The Social Security Advisory Council has been asked by HHS chief
UNINSURED Louis. Sullivan, MD, to focus on health care gaps for Medicaid and the
uninsured. The Council will change its focus and concentrate on health
care for children, the poor, and high-risk populations in the immediate
future to meet Sullivan’s demand.
MANDATORY If employer-sponsored health care coverage were made mandatory, the
QQygpAQg number of uninsured Americans would be reduced by two-thirds. Ap-
proximately 26 million of the.37 million uninsured Americans would be
affected by the mandatory coverage, with 13 million employees covered
through private coverage shifting onto their employer’s coverage.
SMOKING COSTS In connection with his campaign to establish a smoke-free society, HHS
Secretary Louis W. Sullivan, MD, released a report that shows nearly
380,000 Americans died last year from smoking-related diseases. This
report indicates that smoking costs the country $52 billion annually in
health care and lost productivity.
Not considered in Sullivan’s $52 billion calculation is a report by the
Cambridge, Massachusetts-based National Bureau of Economic Re-
search which found that the average male smoker dies before receiving
$20,000 in Social Security benefits and female smokers lose $10,000. This
report concludes that if these people stop smoking, Social Security and
Medicare programs would see their costs rise.
FINI “Learn from, the mistakes of others. You can never live long enough to
make them all yourself.” □
VOL. 87— NUMBER 5 MAY 1990
375
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LEVOXINE® C Levothyroxine Sodium Tablets. USP) For oral administration
The following is a brief summary. Before prescribing please consult package insert
INDICATIONS AND USAGE:
LEVOXINE (L-thyroxine) tablets are indicated as replacement or supplemental therapy
for diminished or absent thyroid function, resulting from functional deficiency, primary
atrophy, from partial or complete absence of the gland or from the effects of surgery,
radiation or antithyroid agents Therapy must be maintained continuously to control the
symptoms of hypothyroidism.
CONTRAINDICATIONS:
L-thyroxine therapy is contraindicated in thyrotoxicosis, acute myocardial infarction
and uncorrected adrenal insufficiency.
WARNINGS:
Drugs with thyroid hormone activity, alone or together with other therapeutic agents, have
been used for the treatment of obesity. In euthyroid patients doses within the range of daily
hormonal requirements are ineffective for weight reduction. Larger doses may produce
serious or even life-threatening manifestations of toxicity, particularly when given in as-
sociation with sympathomimetic amines such as those used for anorectic effects
PRECAUTIONS:
Caution must be exercised in the administration of this drug to patients with cardiovas-
cular disease. Development of chest pains or other aggravation of the cardiovascular dis-
ease requires a reduction of dosage
Patients on thyroid preparations and parents of children on thyroid therapy should be
informed that replacement therapy is to be taken essentially for life They should im-
mediately report during the course of therapy any signs or symptoms of thyroid hormone
toxicity, eg, chest pains, increased pulse rate, palpitations, excessive sweating, heat
intolerance, nervousness, or any other unusual event In case of concomitant diabetes
mellitus, the daily dosage of antidiabetic medication may need readjustment In case of
concomitant oral anticoagulant therapy, the prothrombin time should be measured fre-
quently to determine if the dosage of oral anticoagulants is to be readjusted.
Partial loss of hair may be experienced by children in the first few months of thyroid
therapy, but this is usually a transient phenomenon and later recovery is usually the
rule.
Drug Interactions — In patients with diabetes mellitus, addition of thyroid hormone
therapy may cause an increase in the required dosage of insulin or oral hypoglycemic
agents.
Patients stabilized on oral anticoagulants who are found to require thyroid replace-
ment therapy should be watched very closely when therapy is started
Cholestyramine binds both T4 and T3 in the intestine, thus impairing absorption of
these thyroid hormones Four to five hours should elapse between administration of
cholestyramine and thyroid hormones
Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients without a
functioning thyroid gland who are on thyroid replacement therapy may need to increase
their thyroid dose if estrogens or estrogen-containing oral contraceptives are given.
Drug/Laboratory Test Interactions — The following drugs or moieties are known to inter-
fere with laboratory tests performed on patients taking thyroid hormone: androgens cor-
ticosteroids estrogens oral contraceptives containing estrogens iodine-containing
preparations and the numerous preparations containing salicylates
Carcinogenesis, Mutagenesis And Impairment of Fertility — A reported apparent as-
sociation between prolonged thyroid therapy and breast cancer has not been confirmed
No confirmatory long-term studies in animals have been performed to evaluate car-
cinogenic potential, mutagenicity, or impairment of fertility in either males or females
Pregnancy-Category A — The clinical experience to date does not Indicate any adverse
effect on fetuses when thyroid hormones are administered to pregnant women.
Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human milk
Thyroid is not associated with serious adverse reactions and does not have a known
tumorigenic potential. However, caution should be exercised when thyroid is adminis-
tered to a nursing woman.
Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Routine
determinations of serum (T4) and/or TSH is strongly advised in neonates in view of the
deleterious effects of thyroid deficiency on growth and developmenl
ADVERSE REACTIONS:
Adverse reactions are due to overdosage and are those of induced hyperthyroidism.
OVERDOSAGE — Excessive dosage of thyroid medication may result in symptoms of
hyperthyroidism, which may not appear for one to three weeks after the dosage regimen
is begun. The most common signs and symptoms of overdosage are weight loss, palpita-
tion, nervousness, diarrhea or abdominal cramps, sweating tachycardia, cardiac arrhy-
thmias, angina pectoris, tremors, headache, insomnia, intolerance to heat and fever. If
symptoms of overdosage appear, discontinue medication for several days and reinstitute
treatment at a lower dosage level
Complications as a result of the induced hypermetabolic state may include cardiac
failure and death due to arrhythmia or failure
Dosage should be reduced or therapy temporarily discontinued if signs and symptoms
of overdosage appear.
Treatment of acute massive thyroid hormone overdosage is aimed at reducing gas-
trointestinal absorption of the drugs and counteracting central and peripheral effects,
mainly those of increased sympathetic activity Measures to control fever, hypoglycemia, or
fluid loss should be instituted if needed.
DOSAGE FORMS AVAILABLE:
LEVOXINE (L-thyroxine) tablets are supplied as oval, color coded, potency marked
tablets in 11 strengths: 12 Vi meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - orange,
50 meg (0.05 mg) - white, 75 meg (0 075 mg) purple, 100 meg (0.1 mg) -yellow, 112 meg
(0.112 mg) - rose, 125 meg (0.125 mg) - brown, 150 meg (0.15 mg) - blue, 175 meg
(0.175 mg) -turquoise, 200 mcg(0.2 mg) - pink and 300 mcg(0.3 mg) - green, in bottles of
100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg and
500 meg injectable (see injectable package insert).
376
NEW JERSEY MEDICINE
IF IT AIN’T BROKE The Johns Hopkins Hospital plans to begin random drug testing on all
its full and part time medical staff this summer. To say this has stirred
a bit of controversy is putting it mildly; let us add to the jousting.
Other aspects of the Johns Hopkins’s policy are intriguing. All other
health care personnel are excluded from the new program; only phy-
sicians are targeted. The hospital presently has a program of drug testing
for cause; it has been in place for several years and will continue for
nonphysician people, starting in July. And, most interestingly, when one
considers the individualistic personality of the average physician, it is
reported that the staff has given overwhelming support to the project,
even though reappointments may ride on the results.
We probably should not comment on the legality of such efforts, not
having the requisite legal background or the legal research to buttress
our remarks. But logic suggests at least two reasons why litigation may
be minimal. First, the previous testing for cause, used for several years,
probably has produced few complaints, or the new testing mechanisms
probably would not have been considered. Second, those physicians who
have bargained away part of their individual rights and agreed to testing
also may have lost their right to legal redress, leaving a small cadre of
potential troublemakers who might utilize the court system.
The ethics of mandatory drug testing have been debated for years and
usually involve the principle of collisio jurium, the rights of one group
as opposed to those of another. The AMA policy has been clear: it “does
not support widespread random drug testing of all employees.” George
D. Lundberg, MD, editor of JAMA, once characterized such testing as
“chemical McCarthyism.” As might be expected, the ACLU also dis-
cusses the Hopkins’s plan, feeling it suborns basic individual rights.
Others with experience in drug testing also consider the plan unfortunate
and ill-advised.
We have many reservations and questions about the practicality and
fairness of this testing. How does one insure the accuracy of results? Who
establishes the testing levels denoting impairment, considering the large
number of drugs being tested, including alcohol, cocaine, heroin, com-
mon sedatives, and tranquilizers? If a physician is being treated legit-
imately with any of the drugs being tested, will he be excused or con-
sidered impaired? If 5 to 10 percent of people may have a problem, why
do the other 90 to 95 percent have to be tested, without indication? Will
a glass of wine at dinner disqualify one from acting as a physician until
morning, even in an emergency? Will an oenophilic psychiatrist be ex-
posed to the same testing and strictures as an emergency care physician?
Are nonphysician personnel, such as intensive care unit nurses, IV tech-
nicians, and respiratory therapists, less hazardous to a patient’s health
than a nephrologist or pulmonary specialist? Should members of the
board of governors, ultimately responsible for patient care, also be
tested? Will this can of worms turn into a crate of rattlesnakes?
VOL. 87— NUMBER 5 MAY 1990
381
EDITOR’S DESK
Many dangers should be recognized, even if the testing results are ac-
curate, and if they are not ! If the testing is perceived as being
unwarranted, could resentment also build against more legitimate and
indicated testing? The vagaries of testing and establishing impairment
parameters pose real threats to reputations and practices of staff mem-
bers. Litigation from both patient and physician can be anticipated. If
most of 1,500 doctors can accept this type of program, why couldn’t they
establish solid self-policing activities to deal with the problem of the
impaired physician, rather than placing their fates in the hands of third
parties?
Although Dr. Lundberg has used the term “chemical McCarthyism’’ in
the past, his attitude may have changed and he seems able to accept
this program if certain stringent criteria, such as accuracy of testing,
can be assured. But he also seems to want to out-Koop Koop by asking
that tobacco also be included in the test panel — a proposal that, to be
kind, stretches the definition of impairment to an unacceptable degree.
Dr. Lundberg was more on target when he suggested that responsible,
knowledgeable representatives from medicine, government, and labor
join together to determine reasonable drug testing policies in order to
forestall the splinter activities of individual organizations. We agree
about the need for such a joint venture.
“Lean liberty is better than fat slavery. ”
Thomas Fuller, MD
Gnomologia (1732)
MALIGNANT Skin cancer is the most common form of cancer in the United States.
MELANOMA One form, malignant melanoma, not only has an extremely high mor-
tality rate, but is second only to lung cancer in its rate of increase in
mortality. The article by Dr. Mertz and her colleagues, “Malignant
Melanoma of the Skin” (401-407), presents a discussion of the basic
descriptive epidemiology of malignant melanoma in New Jersey con-
trasted with concurrent national data; examines incidence and mortality
among New Jersey residents; discusses risk factors; and suggests basic
precautionary steps that should be included in prevention and control
strategies, as the summer tanning season approaches. These steps in-
clude: avoiding peak hours of sun intensity and/or prolonged exposure
to the sun; using appropriate sunscreening lotions/creams prior to (and
during) anticipated sun exposure; performing skin self-examination on
a regular (monthly) basis; and consulting a dermatologist for followup
on any suspicious lesions or moles. □
„
382
NEW JERSEY MEDICINE
BOOK
REVIEWS
ACKERMAN’S SURGICAL Juan Rosai, MD. St. Louis, MO, The C.V. Mosby Company, 1989. Since
PATHOLOGY its introduction in 1953, Ackerman’s textbook of surgical pathology has
been a ‘teething ring’ and reference text for pathologists, surgeons, and
other physicians. With steady and rapid increase in medical information,
new editions describing these changes have been necessary. There have
been many changes in the seven-year gap between this and the previous
edition, including new nomenclature, diseases, and lesions, and ad-
vances in technology. The clinicopathological correlations, particularly
of tumors, that made the initial edition so valuable, have been
emphasized, and each section contains important information on pat-
terns of spread and metastases, therapeutic considerations, and prog-
nosis. The text is almost entirely the work of Dr. Rosai. Many sections
have been extensively edited and some entirely have been rewritten. The
chapters on liver, kidney, and bone marrow were prepared with the
assistance of physicians especially knowledgeable in those subjects. The
choice of collaborators was excellent, and the style is remarkably consis-
tent from chapter to chapter.
The organization of the book is classical, with chapters related to major
organ systems. The bibliography following each section is extensive, if
not complete, and is representative enough to lead the reader to original
publications and other authoritative sources. References as recent as
1989 are included. More than 2,000 photographs of gross and microscopic
aspects of disease entities are used, and they are of uniformly excellent
quality. Color reproduction will not be missed by most readers.
Several sections are directed at training pathology residents and include
detailed descriptions of methods for tissue preparation. Other chapters
discuss many of the newest modalities available to pathologists to de-
lineate disease processes. These include immunohistopathological tech-
niques and electron microscopy. A separate section, written by another
associate, describes computerization of surgical pathology records. Keep-
ing the medical community up to date in surgical pathology is no easy
task, and I am happy to see this superb product of Dr. Rosai’s efforts.
The book is a model of clarity and terse completeness. It should gain
wide acceptance by pathologists, clinicians, and medical libraries. If this
all sounds like a rave review — it is. □ Marvin Shuster, MD
DENNEN’S FORCEPS Philip C. Dennen, MD. Philadelphia, PA, F.A. Davis Company, 1989.
Like an old friend from residency days, this revised edition of a standard
text arrived at an opportune moment in the field of obstetrics. Previous
editions long since have been purloined from the medical library by eager
residents desiring to improve their operative techniques.
Sadly, the legal climate has intimidated faculty from passing on their
skills with forceps to the resident staff. This unfortunate trend may have
reached its nadir with efforts now being made to educate patients and
professionals alike as to the safety of a proper forceps delivery. The rise
in cesarean section rates also has contributed to this renewed interest
in operative obstetrics.
VOL. 87— NUMBER 5 MAY 1990
385
BOOK REVIEWS
The author has updated this edition using the new American College
of Obstetricians and Gynecologists (ACOG) classification of outlet, low,
mid, and high forceps. The text and excellent figures clearly demonstrate
the correct application of the various kinds of forceps. I have a bias
against the vacuum extractor and its brief mention is not a deficiency.
This text should be in the hands of all residents. I hope they may have
the satisfaction of using their training with these instruments to help
a patient deliver her child in the best possible condition by the safest
method. □ Gerard F. Hansen, MD
ENHANCED MAGNETIC Val M. Runge, MD (ed). St. Louis, MO, The C.V. Mosby Company,
pg§Q||ANCE IMAGING 1989. This highly specialized monogram addresses two technical aspects
of magnetic resonance imaging (MRI), namely advancement in image
quality improvement and basic and clinical application of contrast
media. The book is divided into four parts, designed to help the reader
through a logical sequence in understanding the rationale and principles
of enhancing the image quality of MRI. Part I, “Imaging Technique,”
compiles five concise chapters outlining the basic principles of signal,
noise, and resolution; the technical aspects of surface coils and the
clinical utilization of these basics to maximize image quality. Part II,
“Contrast Media Principles,” deals with the physical principles of con-
trast enhancement in MRI as well as the pharmacologic characteristics
of various paramagnetic compounds clinically available as contrast
agents. Three chapters in this section deal extensively with the pharma-
cokinetics and toxicity of different gadolinium-based compounds. Part
III, “Contrast Media-Clinical Application,” deals with clinical situations
in a systematic way, covering the central nervous system, spine, head
and neck, cardiovascular system, mediastinum and lung, breast, liver,
kidney and adrenals, pelvis, and musculoskeletal and gastrointestinal
systems. Part IV, summarizes the content of the book.
The book is well written and serves both as a manual and as a reference
to the radiologist who already has had experience in the evolving
supraspecialty of MRI. Although the book is current in latest thoughts
and development in the fast- moving MRI technology, it is doubtful that
it would enjoy more than two years of shelf life before becoming obsolete.
□ Ismail Kazem, MD
Jeffrey L. Brown, MD. Philadelphia, PA, J.B. Lippincott, Co., 1989.
This is a useful book for a general overview of telephone advice for
doctors and nurses. However, I disagree with a number of specific rec-
ommendations. For example: The section on earaches states that the
child should be examined immediately if the child appears toxic. Any
child with a possible ear infection should be examined the same day,
whether they seem toxic or not. By 12 hours later, symptoms may be
much worse. Under the heading for swimmer’s ear, which cannot be
diagnosed on the telephone, there is no mention of the basic treatment
of eardrops containing acidic acid and alcohol. The section on
gastroenteritis relies on the use of the modified WHO solution and half-
strength formula for all cases. Most cases of diarrhea get better by
themselves and need no treatment or change in diet. The section on fifth
disease (erythema infectiosum) does not make mention of the specific
virus, herpes virus 6, that can cause sudden anemia in certain suscep-
tible persons as well as seriously compromise the fetus of a susceptible
pregnant woman.
I feel this book can be recommended for use by anyone who is knowledge-
able. □ Avrum L. Katcher, MD
PEDIATRIC TELEPHONE
MEDICINE. PRINCIPLES,
TRIAGE, AND ADVICE
386
NEW JERSEY MEDICINE
Z LETTERS &
VIEWPOINTS
ACROMEGALY I am curious to learn why radiotherapy was planned and presumably
executed in the patient described by Doctor Goldman in his paper on
acromegaly (86:887-888, 1989). If a benign tumor was completely re-
moved as indicated by Doctor Goldman, what was the purpose of radio-
therapy? If a radiotherapist did radiate this patient, I am curious to
know how much radiation was delivered and over how long a period of
time.
I also am curious to know whether this patient fully recovered. Were
there any sequelae to the radiotherapy? In short, I am interested in the
details of her followup. □ Jerome Abrams, MD
AUTHOR This letter is in response to Dr. Abrams’s comments concerning the
Hg§pQn§£ article on acromegaly (86:887-888, 1989). Transsphenoidal adenomec-
tomy is the most efficient treatment of acromegaly.1 External irradiation
is used in those subjects not suitable for hypophysectomy or where
hypophysectomy has failed to provide adequate reduction of growth
hormone (GH) levels or where residual tumor has been left.2 Recently,
the criteria for optimal hormonal control of acromegaly has become more
well defined realizing that levels of 10 ng/ml post-transsphenoidal resec-
tion may be two to five times over normal concentrations. In the patient
described in our paper, although GH levels decreased to 10 ng/ml, the
somatomedin level remained elevated at 3.2 p/ ml and the surgeon felt
that additional tumor cells remained despite removal of a benign 2 cm
pituitary tumor.
Radiotherapy was given to our patient: 4000 rads over 40 days. Since
that time, GH levels have decreased to 8.4 ng/ml and somatomedin to
3.0 At/ml. Menstruation has returned monthly and overall the patient
feels well. Long-term followup for hypopituitarism from radiotherapy has
been advised. □ Michael H. Goldman, MD
REFERENCES'
1. Serri O, Somma M, Comotis R, et al.: Acromegaly biochemical assessment
of cure after long-term followup of transsphenoidal selective adenomectomy. J
Clin Endocrinol Metab 61:1185-1189, 1985.
2. MacLeod AF, Clarie DG, Pambakian H, et ah: Treatment of acromegaly by
external irradiation. Clin Endocrinol 30:303-314, 1989.
PROFESSIONAL In the February 1990 issue of NEW JERSEY MEDICINE, under the
MEDICAL CONDUCT section entitled, Newswatch, it was reported that S-2936 had been
pgPQI^iyi ^ enacted into law. Eight gains were listed in that report. I was quite
surprised by the inaccuracies in that account and I write this letter in
an attempt to correct the record.
It was stated in Item 5, that a review panel, separate from the Board,
will “investigate and review all but emergent disciplinary cases.” That
is incorrect. The review panel will make recommendations to the Board
and, as we envision it, will hardly be separate from it. More importantly,
the law requires reports of malpractice settlements and reports in reduc-
VOL. 87— NUMBER 5 MAY 1990
389
LETTERS & VIEWPOINTS
tions of hospital privileges to be directed to the panel in the first in-
stance. All other reports will continue to go directly to the Board, includ-
ing consumer complaints, colleague reporting, and information from
police departments, all other law enforcement agencies, all courts and
any other government agencies, and other sources including pharmacies.
It is conceivable that the Board may direct some of these matters to
the panel, but is under no requirement to do so.
Item 8 suggested that the burden of proof was elevated. The existing
law really did not specify a standard of evidence and merely required
proof “to the satisfaction of the Board.” In fact, the Board has consistent-
ly used as its level of satisfaction the standard of “preponderance of the
evidence.” The standard has not at all changed and to suggest that this
new law, in fact, has elevated it, is to misstate the facts.
Item 7 discussed the separation of functions for the deputy attorneys
general. I am unable to find any place in the law which addresses that
issue.
More disturbing is the amount of information about the new law that
was not covered. I have taken the liberty of writing a report covering
many of these points (see page 421). □ Michael B. Grossman, DO,
President, State Board of Medical Examiners
MSNJ
RESPONSE
I have reviewed the letter and materials of February 16, 1990, sent by
Doctor Grossman, president of the State Board of Medical Examiners,
regarding S-2936. I believe Doctor Grossman’s article is a fair accounting
of the new statute. I disagree, however, with the cover letter and particu-
larly his discussion identified as Items 5, 7, and 8.
Items 5 and 7 are a matter involving the application of legal judgment
and statutory construction. Doctor Grossman and I have differing back-
grounds and consequently have used different methodologies in statutory
construction, which have produced disparate opinions. The ultimate
decision in this regard will be made by the courts.
His discussion regarding item 8 is partly accurate. It allowed the Board
to use any standard it wishes, and that statute speaks for itself. The
new statute does require “a preponderance.” That clearly is an improve-
ment, in that it is a quantifiable legal standard beyond the absolute
discretion of the State Board of Medical Examiners. The fact that the
Board was using the preponderance standard did not mean it could not
at any time alter it to a less intensive one such as “mere scintilla.” Thus,
the new statute is indeed a statutory elevation. □ Vincent A. Maressa,
Executive Director/General Counsel, Medical Society of New Jersey
LETTERS TO Letters to the editor are welcome. Communications should be sent to
THE EDITOR NEW JERSEY MEDICINE, MSNJ, Two Princess Road, Lawrenceville,
NJ 08648. □
390
NEW JERSEY MEDICINE
Medical Malpractice
Claims in Cardiology
SUZANNE L. KUEHM, MPH
EMANUEL ABRAHAM, MD
Diagnostic errors are the leading cause of loss in cardiology liability suits.
Physicians could reduce loss by ruling out conditions carrying the greatest
risk if misdiagnosed and by consulting with a radiologist concerning ab-
normal x-rays. Lack of documentation, poor physician communication, and
adverse patient perception also lead to problems.
Since its inception in 1983, the Risk Preven-
tion Department of the Medical Inter-In-
surance Exchange of New Jersey (MIIENJ),
a physician-owned professional liability insurance
carrier, has collected and analyzed data from its
claim files in an attempt to identify specialty-spe-
cific trends in the etiology of medical malpractice
suits. Two objectives of the Department are to de-
crease patient injury and to lower the incidence of
medical malpractice suits.
Ms. Kuehm was a risk analyst with MIIENJ. Dr. Abraham
is director of Ambulatory Care, Jersey Shore Medical
Center and a member of the Board of Governors of the
Medical Inter-Insurance Exchange of New Jersey
(MIIENJ). This manuscript was submitted in October
1989 and accepted in December 1989. Requests for re-
prints may be addressed to Dr. Abraham, MIIENJ, Two
Princess Road, Lawrenceville, NJ 08648.
A total of 115 claim files that were closed with an
indemnity payment to the plaintiff were reviewed.
Only those errors which represent the largest
number of files and reflect a trend will be discussed.
The total indemnity paid on these 115 files was
$11,558,333.
ERROR IN DIAGNOSIS
(49 files— $5,897,025 indemnity paid)
The conditions in which the diagnostic error
occurred, i.e. misdiagnosis, delay in making a
diagnosis, or failure to diagnose, were varied, such
as pulmonary embolism, aortic aneurysm, malig-
nant neoplasm of the lung, myocardial infarction,
and complications of invasive procedures. However,
a failure or delay in recognizing carcinoma of the
lung was the most common. In the majority of these
49 files, the error was one of omission that resulted
VOL. 87— NUMBER 5 MAY 1990
393
in the patient’s death. The recommendations to re-
duce such errors, based on these 49 files, are in-
cluded in the following observations:
1. Office radiology. There were 13 files that re-
vealed a failure or a delay in establishing a diagnosis
of carcinoma of the lung. In 10 files, the carcinoma
of the lung was visible on early chest x-rays that had
been taken in the physicians’ offices. Each claimant
had been a patient of the physician for many years
and all had routine chest x-rays taken in the phy-
sicians’ offices at periodic intervals. The physicians
interpreted the x-rays as “normal” or made a
clinical judgment that the variant findings were of
no significance resulting in a delay (up to 30 months)
in recognizing the existence of the lung cancer. Fre-
quently, the physicians stated the patients had no
symptoms and they took the chest x-rays to evaluate
the heart size; therefore, they were not looking for
pulmonary disease.
Case example. A patient with a history of
rheumatic heart disease had frequent office chest
x-rays taken. The physician noted in the patient’s
record, “Prominent rt. hilar marking but no change
in comparison with the film taken five months
earlier. Feel it doesn’t involve a serious problem.”
Four months later, a chest x-ray showed enlarge-
ment of the shadow. The physician then referred the
patient to a pulmonologist who made the diagnosis
of carcinoma of the lung. The delay eliminated any
possible chance of survival.
Recommendation: Secure the consultation of a
radiologist for x-rays taken in the office that show
any deviation from normal before making a judg-
ment that the findings are not significant. Be aware
that physicians who interpret their own x-rays will
be held to the standard of a radiologist.
2. Appropriateness of diagnostic workup. The
physician/peer reviewer and/or medical defense ex-
pert cited the failure to act promptly to establish a
diagnosis in the face of a life-threatening condition
contributed to the patient’s death. In many cases
when a differential diagnosis included several con-
ditions— one of which could be fatal if not treated
immediately, e.g. pulmonary embolus — the physi-
cian first directed the treatment effort to the less
serious condition such as pneumonia or emphysema.
In cases involving invasive procedures, physicians
often did not consider the most likely complication
first, but directed initial diagnostic and treatment
efforts towards less likely possible complications.
Case example. A 33-year-old woman underwent
elective cardiac catheterization. Several days follow-
ing the procedure, the patient complained of pain
in the arm below the elbow. The physician con-
394
NEW JERSEY MEDICINE
sidered inflammation or hematoma as a diagnosis
and prescribed an anticoagulant and antibiotics.
When no improvement occurred, the physician
prescribed steroids. When the patient’s fingers be-
came cyanotic, she requested a transfer to another
medical facility where her condition was diagnosed
as massive thrombosis of the brachial, radial, and
ulnar arteries. The final outcome was an amputation
below the elbow.
Recommendation: When considering a diagnosis,
first rule out the most serious condition — that which
carries the greatest risk to the patient if mis-
diagnosed. When considering the etiology of a pa-
tient’s symptoms following an invasive procedure,
first consider and rule out the number one complica-
tion of that procedure.
3. Chest pain as presenting symptom. In several
files, the patient was seen either in consultation in
the emergency room or was an established patient
seen in the office with the chief complaint of chest
pain. In some cases the physician failed to evaluate
blood enzymes or incorrectly interpreted an elec-
trocardiogram (EKG). In all the cases, the patient
was sent home and died within 24 hours of a massive
myocardial infarction.
Case example. A 38-year-old male who had short-
ness of breath, left arm pain, and chest pressure
intermittently over a period of one week had been
treated by his family practitioner with trial doses of
antacids, muscle relaxants, and anti-angina medi-
cation with some relief. At the request of the family
practitioner, the patient was seen by a cardiologist
in the emergency room where an EKG was inter-
preted as normal. The patient was discharged to his
home where he died 24 hours later of a massive
myocardial infarction.
Recommendation. In cardiac problems, as in
other life-threatening situations, the patient’s
clinical history frequently is more important than
reliance on a single negative test.
4. Followup. There were several cases where the
physician failed to followup on a patient’s com-
plaints or failed to refer the patient for followup
medical care.
Case example. A patient was seen yearly for four
years following a myocardial infarction. This patient
complained of “a pain in the back” on each office
visit. Since the physician believed it had nothing to
do with heart disease, he did not order a chest
x-ray. After listening to this patient’s complaint
for several years, he referred the patient to a
rheumatologist who ordered a chest x-ray that re-
vealed a 15 cm aneurysm that apparently had been
developing over the years. The patient had emer-
gency surgery but died during the procedure.
Case example. The patient, a known diabetic, was
admitted to the hospital from the emergency room
following a head injury. No neurological consul-
tation was requested. The patient was discharged
with a prescription for Percodan® to treat his head-
ache. The patient was given no instructions to return
for an evaluation of his headache, nor was he advised
to see his own physician. The insured stated he as-
sumed the patient was under the care of a physician
for the diabetes mellitus and, therefore, did not sug-
gest any followup care. Several days later, the pa-
tient’s dentist observed neurological symptoms and
referred him to a neurologist who diagnosed a sub-
dural hematoma, requiring a craniotomy.
Recommendation. Review the notations made in
the patient’s chart (office and hospital) during the
previous visit to ensure followup on previously ob-
served clinical findings. Instructions for followup
care for patients seen in the hospital (emergency
room or admitted) should be written, handed to the
patient, and documented in the chart.
5. Concurrent care. When more than one phy-
sician was treating the patient concurrently, the
physicians often were unclear as to whose responsi-
bility it was to treat new evolving symptoms. As a
result, neither addressed the patient’s problems and
the condition became worse.
Case example. Following a cardiac catheteriza-
tion, a patient developed signs of infection — pain,
temperature of 103°, and purulent drainage from the
catheter site. The cardiologist took no action. The
primary physician saw the patient daily and re-
corded his observations of the above symptoms in
the chart, but he also took no action believing it was
the responsibility of the cardiologist who performed
the catheterization to order a culture and sensitivity
test on the drainage. Nineteen days later, a blood
culture was positive for Staphylococcus aureus. The
patient died a few days later of overwhelming sepsis.
Recommendation. The attending physician must
maintain primary responsibility for the patient even
when the presenting symptoms may be a result of
a procedure performed by another physician.
6. Role of consultant. Frequently, patient care
was compromised because the consultant was un-
clear about his role and responsibility to the patient
and the referring physician.
Case example. A 37-year-old woman complained
of shortness of breath, a tearing sensation in her
neck, and chest pain. The cardiologist requested a
consultant to perform a cardiac catheterization. The
consultant came into the hospital that weekend,
examined the patient, and scheduled a cardiac
catheterization. The consultant later stated he
thought he had been called in as a “technician,” i.e.
to perform a procedure, and therefore he did not read
the patient’s chart. He further admitted that if he
had read the chart he would have noted her blood
pressure readings were unequal, and he would have
VOL. 87— NUMBER 5 MAY 1990
395
done the complete study that same evening. His
delay in performing the diagnostic study led to
further delays in establishing the diagnosis of dis-
secting aortic aneurysm and subsequent surgery.
The patient’s condition deteriorated over the week-
end and the patient died during emergency surgery.
Recommendation. The role of the consultant is
to evaluate the patient and the data accumulated
in order to render a diagnosis or an opinion and
recommend further care. Communication with the
referring physician, both before and after performing
the consultation, is an essential element of the con-
sultation.
7. Records. An incomplete patient record fre-
quently led to a diagnostic error: either not enough
information was recorded regarding the patient’s
symptoms or the physician did not elicit a complete
history.
Case example. A young man alleged that his
cardiologist failed to conduct a stress test and, there-
by, failed to diagnose coronary artery disease. A
subsequent treating cardiologist made the diagnosis
ten months later. The patient stated that he told the
first cardiologist he had chest pain. The record did
not reflect this. It was the opinion of the peer re-
viewer that the history as recorded was not detailed,
yet the patient had risk factors of hypertension and
cigarette smoking plus symptoms of fatigue and
shortness of breath when climbing stairs. The poorly
documented record failed to acknowledge the pa-
tient’s complaints at the time of the examination
eight to ten months earlier which could have led the
cardiologist to consider a stress test to rule out cor-
onary artery disease. The diagnosis ultimately was
made by another cardiologist after the patient suf-
fered a myocardial infarction.
Recommendation. A good record reflects both the
positive and negative findings of the patient’s his-
tory. Document the thought process that resulted in
the action taken. Consider the use of a record form
such as the Problem-Oriented Medical Record (sub-
jective, objective evaluation, assessment, and plan).
8. Office systems. There were several files where
the physician failed to read an x-ray report or a copy
of an emergency room record. These reports had
been filed in the patient’s record before the phy-
sician read them.
Recommendation. Develop an office system to
ensure that you see all reports before they are filed
into the patient’s chart. This could be accomplished
by initialing all reports after you have read them.
DECISION ERRORS
(13 files— $847,033 indemnity paid)
In this category, a review of patients’ records re-
vealed faulty decisions had been made by the pa-
tients’ physicians. Obviously, the physicians in-
volved did not know their decisions were faulty at
the time. Only one file involved an error of com-
mission. The remaining files all concerned errors of
omission and delay. The following are examples of
the errors in this category.
Case example. A 51-year-old patient with a his-
tory of rheumatic heart disease and mitral stenosis
with atrial fibrillation was seen regularly by her
cardiologist. The cardiologist was undecided about
whether to prescribe anticoagulants. He requested a
second opinion of another cardiologist. This consul-
tant recommended curtailed activities, considerable
bed rest, and anticoagulant therapy. The primary
cardiologist disregarded this recommendation. He
knew the patient had an active lifestyle and for this
reason decided not to prescribe anticoagulant ther-
apy. Before making his decision, the primary car-
diologist never discussed the options and risks with
the patient. Several months later, the patient died
suddenly. The insured’s reasoning implied (and
records showed) he recognized the medical need for
anticoagulant therapy. But he decided not to
prescribe anticoagulant therapy for the wrong
reason — the patient’s active lifestyle.
Case example. A 30-year-old patient with a his-
tory of rheumatic fever with aortic and mitral
stenosis complained of increasing exertional dyspnea
interfering with his job. A chest x-ray showed moder-
ate cardiac enlargement with pulmonary congestion.
He was referred by his family physician to a
cardiologist. The family physician accepted a 15-day
wait for an appointment to the cardiologist. The
cardiologist examined the patient, but did not
prescribe medication for symptoms of congestive
heart failure. Another 15 days later, the cardiologist
scheduled a cardiac catheterization and accepted a
16-day wait. The patient died 1 day after the
cardiologist had scheduled the procedure — 46 days
after the family physician had referred the patient
to the cardiologist. In this case, both physicians ex-
ercised bad judgment in accepting the excessive de-
lays.
Recommendation. Carefully consider the advice
and directives of a specialist before deciding on a
treatment plan. Schedule diagnostic tests in a time-
ly manner, especially if the patient is at great risk
of a serious or fatal outcome.
COMMUNICATION BREAKDOWN
Although there were few indemnity dollars paid in
which a breakdown in communication was the pri-
mary cause, there were many files where the com-
munication breakdown was a significant contribut-
ing factor in the patient’s injury or death and the
resulting suit.
1. Communication with other physicians. Corn-
396
NEW JERSEY MEDICINE
munication involves consultants, the patient’s prior
treating physician, and other associates in the same
practice. Situations where a failure to communicate
contributed to or actually caused a bad result in-
cluded: an attending physician failing to com-
municate the severity of a patient’s condition to a
consultant upon request for a consultation resulting
in a delay in treatment and the patient’s death; a
physician failing to familiarize himself with the de-
tails of a patient’s condition and treatment after he
assumed care of this patient from another medical
facility leading to a complication after surgery due
to a disease the physician was not aware of and to
the subsequent death of the patient; and associates
in the same practice failing to communicate critical
medical information to one another.
Case example. A young woman was referred to a
cardiologist who made a preliminary diagnosis of
dissection of the thoracic aorta (the correct
diagnosis). He wrote in the patient’s record, “The
patient is at considerable risk.” The cardiologist did
not admit the patient to the hospital nor did he relay
this information to his partner who was covering the
practice for the weekend. There was a failure to act
upon an emergent situation for 10 to 12 hours. It was
the peer reviewer’s opinion that this delay con-
tributed to the patient’s eventual death.
Recommendation. Direct communication in per-
son or on the telephone with a consultant is essen-
tial, especially if you suspect a patient may be
experiencing a life-threatening event. When you
know a patient has been under the care of another
physician, communicate directly with that physi-
cian regarding the patient’s medical condition, past
medical history, and current medications. Also, if
possible, secure the record of the most recent hospi-
talization. Develop an office system that ensures all
critical patient information is transmitted to cover-
ing physicians. This becomes increasingly important
as the number of associates in the clinical practice
increases.
2. Communication with family. There are many
instances where a patient’s family can help or hinder
the physician in the medical treatment of the pa-
tient. It also is not uncommon that a family member
institute a medical malpractice lawsuit because of
a misunderstanding or a misperception of the medi-
cal treatment rendered to a relative.
Case example. A patient, treated for a leg ulcer,
had elevated blood sugar. The physician pre-
scribed insulin, but the patient’s wife refused to
permit its administration. The infection did not re-
spond to the antibiotic therapy— the blood glucose
gradually rose and the patient also developed septic
shock. There was no attempt to explain the treat-
ment rationale to the patient’s wife. The physician
gave in to the demands of the patient’s family.
Recommendation . Explain to the patient’s family
what it is you are attempting to accomplish. Main-
tain objectivity; do what is right for the patient.
CARDIAC CATHETERIZATION
(9 files— $768,066 indemnity paid)
1. Risk of the procedure. There were several ex-
amples where the common complications of the
procedure were not diagnosed in a timely manner
and treated when they occurred, e.g. the develop-
ment of an embolism or the development of an infec-
tion at the site of catheter insertion. This resulted
in death, permanent disability, or prolonged hospi-
talization.
2. Inattention. In two instances, the physician
either failed to check the intravenous setup prior to
the procedure or did not notice the setup was incor-
rect. In one case, an air embolism resulted in the
patient’s death; in the other case the patient de-
veloped a hemiparesis.
3. Patient perception. There were several files
where relatively minor complications appear to have
been the cause of a medical malpractice suit because
the patients perceived that they were being ignored
or not taken seriously by their physicians.
Case example. A patient complained of a “pins-
and-needles” sensation following cardiac cathe-
terization and asked the nurse to notify the phy-
sician. The nurse responded, “Your doctor is gone
for the day and cannot be reached.” The comment
made by the nurse may have implied to the patient
that no one really cared about him and his medical
condition. After a delay, the house physician
checked the patient’s extremity, pronounced it
“O.K.,” and discharged him. The following day, the
patient was seen in an emergency room where he was
found to have an arterial occlusion and was sched-
uled for an embolectomy. In this case, the patient
may have perceived that his complaints were not
taken seriously and this perception may have trig-
gered the lawsuit.
Case example. Following a cardiac catheteriza-
tion, a patient reported to his physician that there
was bleeding from the catheterization site. The phy-
sician responded, “Don’t worry, it will be alright.”
Two days later, the incision was still bleeding and
the patient’s hand and arm were swollen and pain-
ful. The patient sought treatment at an emergency
room where the wound was redressed. The patient
was advised to call if any additional bleeding was
observed. The following day, because of continued
bleeding, the wound was explored and resutured.
This second physician informed the patient that the
incision had been improperly sutured initially. After
this, there was no further bleeding and the symp-
toms abated. In this example, the patient may have
perceived that the first physician minimized or dis-
VOL. 87— NUMBER 5 MAY 1990
397
credited the importance of his complaint by offering
reassurances without any attempt to investigate the
etiology of the bleeding. This compounded the fail-
ure to recognize the complication. It also should be
recognized that the second treating physician may
have induced the medical malpractice suit by his
comment to the patient.
Recommendation. Showing concern for and
interest in the patient’s condition goes a long way
in preventing a malpractice action, especially if
minor complications seem to be the “cause” of the
suit.
STRESS TEST
(7 files— $857,833 indemnity paid)
In all of these suits, the patients died following the
stress test. Several trends appeared involving de-
cisions and perceptions.
1. Conduction of the test. In six of these files, the
physician was not in attendance during the test. The
patient was attended by the technician who made
the decision to continue or discontinue the test.
Recommendation. The decision to continue or
discontinue the stress test should be based upon the
physician’s evaluation of the patient’s complaints
and the data received.
2. Decision flaws. In several files, a significant
decision made by the physician placed the de-
fensibility of the case, in light of the fatal outcome,
in a grey area by the peer reviewer and/or the medi-
cal defense expert.
In several files, the patient’s anti-angina medi-
cation was discontinued the morning of the stress
test.
One patient had a Holter monitor test conducted
24 hours prior to undergoing the stress test, but the
results were not available until several days after the
patient had died during the stress test. The Holter
monitor revealed the patient had experienced a
myocardial infarction when he complained of chest
pain (presumed angina) the night before the stress
test.
Often the peer reviewer and/or medical defense
expert expressed the opinion, “There was nothing to
be gained from the stress test, and therefore the
patients were deprived from living out their natural
lives.” Such patients either previously had diag-
nosed coronary artery disease (by cardiac catheter-
ization) or had such severe claudication that their
self-imposed activity would never have equalled the
activity of the stress test.
Recommendations. Provide a careful explanation
to family members of the rationale behind the de-
cision to discontinue anti-angina medication before
the conduction of the stress test. If such an expla-
nation is not given, and there is a fatal outcome, the
family may perceive that the decision to discontinue
the anti-angina medication was an erroneous one
and was the cause of the patient’s death. Obtain the
results of all prior tests before proceeding with ad-
ditional testing if there is any possibility that these
results could alter the decision to perform the ad-
ditional test. Carefully consider what is to be gained
from the stress test and proceed only if the result
outweighs the risk involved.
3. Family perception. Since all of these files in-
volved the sudden death of the patient, it appears
as though anything that made the family believe
that the medical professionals were unconcerned or
unresponsive to the patients’ plight contributed to
the decision to sue.
Case example. Following a stress test, the patient
was transported back to his room. Within a short
period of time he complained of chest pain and
shortness of breath, and was diaphoretic. The pa-
tient’s wife requested assistance from the consulting
cardiologist who was at the nurses’ station. The
cardiologist responded, “He’s not my patient. Con-
tact his attending doctor.” This was verified by sev-
eral persons who were present to hear the conversa-
tion. It was soon after this incident that the patient
expired.
Recommendation. The perceptions that a pa-
tient’s family member has of the physician is just
as important as the patient’s. Flippant or thought-
less remarks may come back to haunt the treating
physician.
SUMMARY
In the specialty of cardiology, diagnostic error ac-
counted for the greatest single category of loss, rep-
resenting 43 percent of all files. There were a total
of 13 files where there was a failure or a delay in
making a diagnosis of carcinoma of the lung. In 10
of these files, the diagnostic error occurred because
the physician misinterpreted a chest x-ray taken in
his office. In two additional files, the diagnostic error
occurred because the physician did not see the x-ray
report before it was filed into the patient’s chart.
Peer reviewers and/or medical defense experts often
cited a failure to recognize the most common com-
plication of a procedure when it did occur and a lack
of aggression in first ruling out a life-threatening
condition before initiating treatment of less serious
possible conditions. A breakdown in communica-
tion— physician to associate, consultant to primary
physician, and physicians of different specialties
treating the patient together — frequently resulted in
fatal patient outcomes. And finally, but of equal
importance, it appeared that perceptions by the pa-
tient and the family members regarding the quality
of medical care received played an important role in
the decision to sue. This especially was true when
a fatal outcome occurred. ■
398
NEW JERSEY MEDICINE
Malignant Melanoma
of the Skin
KRISTEN MERTZ, MD
HENRY C. LEWIS, JR, MPH
LAWRENCE A. MEINERT, MD, MPH
Each year, several thousand New Jersey residents are diagnosed with skin
cancer, the most common form of cancer. One form of skin cancer, malig-
nant melanoma, has a high mortality rate. This report examines melanoma
rates from 1979 to 1985, and suggests basic precautionary steps necessary
for prevention and control of this disease.
The incidence and mortality rates for malig-
nant melanoma of the skin have been in-
creasing steadily in the United States over
the past several decades. The national mortality rate
for melanoma of the skin rose 25.9 percent from 1973
to 1985, a greater percentage increase for any cancer
except lung cancer.1 The mortality rate for white
males over the same time period increased 34.1 per-
cent, the highest percentage increase of any cancer
for this particular population.1 The American
Cancer Society estimates that the number of new
From the New Jersey State Department of Health,
Division of Epidemiology and Disease Control. This
paper was submitted in January 1990 and accepted in
February 1990. Requests for reprints may be addressed
to Dr. Parkin, NJDOH, Division of Epidemiology and Dis-
ease Control, CN 360, Trenton, NJ 08625-0360.
cases of malignant melanoma will rise to 27,000, and
that 6,000 Americans will die from the disease.2
Melanoma has been linked to intermittent ex-
posure to high-intensity ultraviolet radiation.3'6 The
emphasis in this country on suntanning and outdoor
recreation may account for the high rate of increase
in melanoma cases. In the future, the depletion of
the ozone layer, allowing for increased penetration
of ultraviolet light to the earth’s surface, also may
contribute to an increase in the number of melan-
oma cases.6,7
New Jersey has an extensive coastline utilized for
outdoor recreation and suntanning, and, thus, the
state may be expected to have relatively high rates
of melanoma. This is likely to be partially offset by
the northern location of the state, because there is
an inverse relationship between latitude and melan-
VOL. 87-NUMBER 5 MAY 1990
401
HHH
INCIDENCE PER 100,000
SEER White
Females
SEER White
Males
-NJ White
Females
ii NJ White
Males
Year of Diagnosis
Figure 1 . Age-adjusted incidence rates for melanoma of the skin, 1979 to 1985 (adjusted to 1970 U.S. standard).
MORTALITY PER 100,000
15
10
5
i i i i i i i
1979 1980 1981 1982 1983 1984 1985
US White
Females
US White
Males
- - - - NJ White
Females
— NJ White
Males
Year of Death
Figure 2. Age-adjusted mortality rates for melanoma of the skin, 1979 to 1985 (adjusted to 1970 U.S. standard).
oma incidence in whites in most parts of the
world.8-9 This report examines melanoma rates in
New Jersey for the years 1979 to 1985 and compares
them to concurrent national rates.
METHODS
Incidence data for malignant melanoma of the
skin in New Jersey are taken from the New Jersey
State Cancer Registry (NJSCR) within the New Jer-
sey State Department of Health. NJSCR, in ex-
istence since 1979 when cancer became a reportable
disease in the state, receives case reports from hospi-
tals, laboratories, and private practitioners. The
melanoma incidence data for this report exclude in
situ cases and include cases identified solely by
death certificate.
The mortality data for malignant melanoma in
New Jersey are extracted from the state’s vital
statistics mortality tapes and include cases with ma-
lignant melanoma of the skin listed as the under-
lying cause of death.
Population estimates used to calculate incidence
and mortality rates for New Jersey were supplied by
the National Cancer Institute (NCI) for the years
1980 to 1985. Rates for 1979 are calculated using 1980
estimates.
National incidence and mortality rates are taken
from the Cancer Statistics Review 1973-1986, pub-
lished by NCI.10 Information (annual average age-
402
NEW JERSEY MEDICINE
US White
Females
NJ White
Females
US White
Males
— NJ White
Males
Five-Year Period
*(1972 excluded from 1970-1975 Average)
Figure 3. Age-adjusted mortality rates for malignant melanoma of the skin (adjusted to 1960 U.S. standard).
Table. Five-year average mortality per 100,000.
White Males White Females
NJ
US
Ratio
NJ
US
Ratio
1950-1954
1.33
1.17
1.14
0.90
0.90
1.00
1955-1959
1.36
1.36
1.00
1.00
1.05
0.95
1960-1964
1.65
1.64
1.01
1.10
1.17
0.94
1965-1969
1.97
1.90
1.04
1.36
1.28
1.06
1970-1975*
2.45
2.19
1.12
1.34
1.39
0.96
1981-1985
3.45
2.94
1.17
1.96
1.63
1.20
*(1972 excluded from 1970 to 1975 average)
specific rates, staging distribution, and survival
rates) for the appropriate time frames not available
in this edition is taken from NCI’s 1987 Annual
Cancer Statistics Review. The mortality rates cover
the entire United States. The incidence rates rep-
resent cases from nine population-based registries
throughout the United States that comprise the
Surveillance, Epidemiology, and End Results
(SEER) Program of NCI. Like the data for New
Jersey, the data for the SEER Program exclude in
situ cases and include cases identified by death
certificate only. Of note, the four most populated
counties in the state New Jersey have participated
in the SEER Program since the end of 1983 but the
data are not included in any of the SEER publi-
cations.
New Jersey and United States mortality rates for
five-year intervals during 1950 to 1975 are taken
from a table depicted in Descriptive Epidemiology
of Cancer Mortality in New Jersey: 1949-1976. 11
These rates are age-adjusted to the 1960 U.S. stan-
dard population and, thus, cannot be assumed to be
directly comparable with rates for the 1980s that are
age-adjusted to the 1970 U.S. standard population.
Sufficient information was available, however, to
readjust the rates from 1981 to 1985 for malignant
melanoma mortality in New Jersey and the United
States to a common age distribution of the 1960 U.S.
standard population, allowing the graphic com-
parison in Figures 3 and 4.
RESULTS
In New Jersey, an average of 381 males and 324
females per year were diagnosed with melanoma of
the skin during the years 1979 to 1985. An average
of 111 males and 79 females died each year from
melanoma during the same time period.
The age-adjusted incidence rates for melanoma of
the skin for white males and white females in New
Jersey, 1979 to 1985, are presented in Figure 1. Mel-
anoma incidence rates for the SEER Program for the
same years are added for comparison. New Jersey
white males have the highest average incidence rate
for the seven-year period (11.9/100,000), followed by
SEER white males at 10.9/100,000. The white female
populations have lower rates at 8.8/100,000 for
SEER white females and 8.5/100,000 for New Jersey
white females. The incidence rates for blacks in New
Jersey are very low (1.1/100,000 for black males and
1.2/100,000 for black females), and thus the analyses
VOL. 87— NUMBER 5 MAY 1990
403
presented here are for the white population only.
New Jersey melanoma incidence rates consistent-
ly are higher than SEER rates for white males but
not always for white females. The average New Jer-
sey to SEER ratio over the seven-year period is 1.1
for white males and 1.0 for white females. The in-
cidence rates for all four populations increased over
the seven-year period, with the largest percentage
change for SEER white males (20 percent).
The age-adjusted mortality rates for malignant
melanoma of the skin in New Jersey and in the
United States as a whole (1979 to 1985) are pre-
sented in Figure 2. Again, the rates for blacks are
very low and are excluded from our analyses. The
percent change in mortality rates over the seven-
year period is highest for New Jersey white males
(12.9 percent). Within the white population, the
rates for males are higher than the rates for females.
For both sexes the New Jersey rates are higher than
the national rates and the average New Jersey to
United States mortality ratio for the seven-year
period is 1.2 for both white males and white females,
respectively. These ratios are higher than the New
Jersey to SEER incidence ratios.
In Figure 3 and the Table, average age-adjusted
mortality rates for selected five-year intervals from
1950 to 1985 (excluding 1976 to 1980) are presented
for both New Jersey and the United States. This
clearly delineates a progressive increase in age-ad-
justed mortality rates over a 35-year period and in-
dicates a possible divergence in recent years between
New Jersey and national mortality rates for both
males and females. Figure 4 shows the ratio of New
Jersey to United States age-adjusted mortality rates
for each of the intervals displayed in Figure 3. This
indicates that the disparity between New Jersey and
NJ/US RATE RATIOS
White
Males
White
Females
Five-Year Period
*(1972 excluded from 1970-1975 Average)
Figure 4. Rate ratio: Malignant melanoma mortality (using rates adjusted to 1960 U.S. standard population).
INCIDENCE PER 100,000
SEER White
Females
SEER White
Males
— ■ — NJ White
Females
— — — 1 NJ White
Males
Five-Year Age Group
Figure 5. Age-specific incidence rates for melanoma of the skin, 1981 to 1985.
404
NEW JERSEY MEDICINE
national melanoma mortality rates has remained
fairly stable over this 35-year period.
To further compare New Jersey versus national
data, melanoma rates are expressed as a percentage
of total cancer rates for white males and females
during the years 1979 to 1985. For white males, the
average melanoma incidence rate accounts for 2.6
percent of the total cancer incidence rate in both
New Jersey and the SEER Program. For white
females, the average melanoma incidence rate as a
percentage of the average total cancer incidence rate
is greater for the SEER Program than for New Jersey
(2.7 percent and 2.4 percent, respectively). Com-
parison of average melanoma mortality rates as a
percentage of average total cancer mortality rates
shows that melanoma accounts for a similar per-
centage of cancer deaths for both white males and
white females in New Jersey as in the nation as a
whole.
The average age-specific melanoma incidence
rates (1981 to 1985) for white males and white
females in New Jersey and in the SEER Program
increase with age (Figure 5). The rate of increase in
the older age groups is much higher for white males
than for white females, for whom rates increase only
slightly after age 50. Age-specific mortality rates for
melanoma increase steadily as age increases for all
four populations (Figure 6).
The five-year relative survival rates for melanoma
patients are not strictly comparable for New Jersey
and SEER because they cover slightly different time
periods and SEER rates are not stratified by sex.
New Jersey’s five-year relative survival rates for
white patients diagnosed with malignant melanoma
at any stage of disease during the years 1979 to 1985
are 63 percent for males and 76 percent for females.
These survival rates are lower than SEER’s five-year
relative survival rate of 80 percent for white patients
diagnosed with melanoma during the years 1979 to
1984.
In New Jersey, 73 percent of melanomas
diagnosed in 1979 to 1984 in white males and white
females were staged as local, compared with 78 per-
cent in the SEER Program (Figure 7). The per-
centage of cases staged as regional or distant was
similar for New Jersey and SEER (16 percent and
14 percent, respectively).
The most common site for melanoma of the skin
in the New Jersey population, 1979 to 1985, is the
trunk for white males (48 percent of the cases for
which site was identified) and the leg and hip for
white females (38 percent of the cases for that site
was identified) (Figures 8 and 9). This finding is
consistent with previous reports citing the most
common sites as the back for men and the lower
extremity for women.912
DISCUSSION
Incidence and mortality rates for malignant mel-
anoma of the skin are increasing in New Jersey, as
they are in many places in the world. This increase
in melanoma mortality is very noteworthy when age-
adjusted rates are observed over the past 35-year
period (1950 to 1985). This evidence reveals an in-
crease of nearly 250 percent. Mortality rates for
white males and white females are slightly higher in
New Jersey than in the United States. When com-
paring the ratio of New Jersey to United States
death rates, however, it appears that the slight dis-
parity between New Jersey and United States mor-
tality rates for melanoma is relatively stable over
time.
US White
Females
US White
Males
NJ White
Females
— NJ White
Males
0- 10- 20- 30- 40- 50- 60- 70- 80-
5- 15- 25- 35- 45- 55- 65- 75- 85 +
Five-Year Age Group
Figure 6. Age-specific mortality rates for melanoma of the skin, 1981 to 1985.
VOL. 87— NUMBER 5 MAY 1990
405
PERCENTAGE OF TOTAL CASES
100
NJ Whites SEER Whites
0223 Unknown
i I Regional and
Distant
Local
Figure 7. Stage distribution tor melanoma of skin, for male and female cases diagnosed 1979 to 1984,
New Jersey versus SEER.
NEW JERSEY WHITE MALES
22.7% ARM &
SHOULDER
Figure 8. Site distribution for melanoma cases of known site,
diagnosed 1979 to 1985.
NEW JERSEY WHITE FEMALES
TRUNK 23.5%
ARM &
SHOULDER
24.0%
4.3% SCALP &
NECK
10.1% FACE
38.1% LEG & HIP
Figure 9. Site distribution for melanoma cases of known site,
diagnosed 1979 to 1985.
The change in incidence rates for New Jersey for
malignant melanoma over a 35-year period cannot
be determined since incidence data were not col-
lected prior to 1979. However, recent New Jersey
data (1979 to 1985) indicate that, as with the other
SEER registries, the incidence of malignant mela-
noma is the most rapidly rising of any cancer for
white males and the second most rapidly rising
(after lung cancer) for white females.
Of note, NJSCR is relatively new in comparison
with many of the SEER registries, and case report-
ing in this state may be more limited than in the
SEER Program. The sensitivity of the registry with
respect to case reporting is that the total number of
melanoma cases in the community being detected
by the system is fairly high, though presumed to be
less than 100 percent. The reason for incompleteness
in reporting is due to a combination of factors in-
cluding increased trends towards earlier diagnosis
and treatment in private physicians’ offices backed
by pathological investigations by private labora-
tories, both of which show very poor compliance with
reporting to the registry. The net result is under-
reporting of outpatient cases at the local stage of
diagnosis. While this is a common problem shared
by all registries, New Jersey faces the additional
problem of unreported cases that are diagnosed and
treated at private facilities in New York and Phila-
delphia. This potentially would lower the sensitivity
of NJSCR.
NJSCR identified a greater percentage of cases
solely by death certificates during its early years of
existence than during its later years (15 percent
versus 6 percent). As many as half of these cases
identified by death certificates were diagnosed prior
to 1979. This should spuriously elevate the incidence
rates for melanoma during these early years (1979
to 1981) more than for later years (1982 to 1985). As
406
NEW JERSEY MEDICINE
a result, the “true” upward trend in cancer in-
cidence rates may be greater than actually is pre-
sented in this report.
The causes of malignant melanoma are not well
understood, though the disease has been linked to
several risk factors, including intense intermittent
sun exposure, indoor occupation and outdoor rec-
reation, inability to tan, blistering sunburns in
childhood, blue eyes, red or blonde hair, light com-
plexion, history of melanoma or other skin cancer,
and a large number of nevi on the skin.1315 There is
no obvious reason why New Jersey’s population
should differ from the SEER population with respect
to these risk factors. The nine SEER registries (At-
lanta, Detroit, Seattle/Puget Sound, San Francisco-
Oakland, Connecticut, Iowa, New Mexico, Utah,
and Hawaii) cover a diversity of geographic areas
and climates, but a majority of them either have a
coastline like New Jersey or a more southern latitude
than New Jersey. Thus, it is not surprising that New
Jersey and the SEER Program have similar in-
cidence rates for melanoma of the skin.
The reason for both the higher rates and the up-
ward trend in the rates for melanoma incidence and
mortality among white males as compared with
white females is unclear. Are men at higher risk due
to occupational exposures? Do women have less ex-
posure to ultraviolet light, a greater tendency to use
sunscreen, or some other protective factor?
One cause for concern is the apparent lower five-
year survival rate for whites in New Jersey as com-
pared with the other regions in the SEER Program.
This could be a contributing factor to New Jersey’s
higher melanoma mortality rates. The lower survival
rate may be a reflection of diagnosis at later stages
of disease, because a smaller percentage of whites in
1. National Institutes of Health: Annual Cancer
Statistics Review. Bethesda, MD, National Cancer In-
stitute, United States Department of Health and Human
Services, 1988.
2. American Cancer Society: Cancer Facts & Figures —
1989. Atlanta, GA, 1989.
3. Mackie RM: The role of sunlight in the aetiology of
cutaneous malignant melanoma. Clin Exp Dermatol
6:407-410, 1981.
4. Armstrong BK, Holman CD: Malignant melanoma
of the skin. Bull WHO 65:245-252, 1987.
5. Armstrong BK: Epidemiology of malignant melan-
oma: Intermittent or total accumulated exposure to the
sun? J Dermatol Surg Oncol 14:835-849, 1988.
6. Jones RR: Ozone depletion and cancer risk. Lancet
8556:443-446, 1987.
7. Krimpke ML: Impact of ozone depletion on skin
cancers. J Dermatol Surg Oncol 14:853-857, 1988.
8. Fears TR, et al.: Skin cancer, melanoma, and
sunlight. Am J Public Health 66:461-464, 1976.
9. Kopf AW, et al.: Sun and malignant melanoma.
J Am Acad Dermat 11:674-684, 1984.
10. National Institutes of Health: Annual Cancer
New Jersey are diagnosed at a local stage compared
with whites in the SEER Program. This underscores
the need to strive for earlier diagnosis in New Jersey.
The age-specific incidence rates for whites in-
dicate that melanoma is very rare for children and
adolescents, but occurs much more frequently in the
middle-aged and elderly populations. At present,
the American Cancer Society recommends skin
examinations annually for people over age 40, and
every three years for those between the ages of 20
and 40. 16 The New Jersey data support the need for
this guideline. A particular focus of screening ac-
tivities on elderly white males may be indicated.
SUMMARY
Malignant melanoma of the skin deserves more
attention from the health care community. Not only
is more research needed to examine the etiological
factors of malignant melanoma, but there is a need
to develop a comprehensive strategy of prevention
and control. Education of the public about the need
to minimize exposure to ultraviolet radiation should
be enhanced. This especially is important for chil-
dren and adolescents because an estimated 50 per-
cent of total lifetime sun exposure occurs by 18 years
of age.12 Education should include teaching the pub-
lic the warning signs of melanoma and offering cost-
effective screening services. The Dermatologic So-
ciety of New Jersey, in conjunction with the Ameri-
can Cancer Society, conducts free screening program
at various locations around the state; such screening
efforts need to be expanded into the routine practice
of primary care physicians. Prevention and early
detection are the most effective ways to stem the
rapid rates of increase in melanoma incidence and
mortality. ■
Statistics Review. Bethesda, MD, National Cancer In-
stitute, United States Department of Health and Human
Services, 1989.
11. New Jersey State Department of Health, Cancer
Epidemiology Program, Division of Epidemiology and Dis-
ease Control: Descriptive Epidemiology of Cancer Mor-
tality in New Jersey: 1949-1976. Trenton, NJ, 1981.
12. National Institutes of Health: Sunlight, ultraviolet
radiation, and the skin. Consensus development con-
ference statement, May 1989.
13. Holman CD, Armstrong BK: Pigmentary traits,
ethnic origin, benign nevi, and family history as risk fac-
tors for cutaneous malignant melanoma. J Natl Cancer
Inst 14:397-407, 1988.
14. Evans RD, et al.: Risk factors for the development
of malignant melanoma — I: Review of case-control stud-
ies. J Am Acad Dermatol Surg Oncol 14:397-407, 1988.
15. Kopf AW, Maize JC: Cutaneous malignant melan-
oma. J Am Acad Dermatol 16:610-613, 1987.
16. Koh HK, et al.: Screening for melanoma/skin
cancer: Theoretic and practical considerations. J Am Acad
Dermatol 20:159-172, 1989.
VOL. 87— NUMBER 5 MAY 1990
407
YOCON
YOHIMBINE HCI
Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine’s peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.
Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone
Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it, however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.
Indications: Yocon* is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac
Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications
Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.
Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.1 2 Also dizziness,
headache, skin flushing reported when used orally.1 3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 '3-4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon? 1/12 gr. 5.4 mg in
AVAILABLE AT PHARMACIES NATIONWIDE
bottles of 100’s NDC 53159-001-01 and 1000’s NDC
53159-001-10.
References:
1. A. Morales et al. , New England Journal of Medi-
cine: 1221. Novembers, 1981.
2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed . , p . 176-188.
McMillan December Rev. 1/85.
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales et al. , The Journal of Urology 128:
45-47, 1982.
YOCON*
1000 TABLETS
Rev. 1/85
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408
NEW JERSEY MEDICINE
Luetic Aortic
Aneurysm
Presentation of Acute Illness
jock n. McCullough, md
RONALD M. ABEL, MD
Luetic aortitis no longer is a forgotten clinical entity. A patient with an expand-
ing aneurysm of the aortic arch required urgent surgical resection during
the acute phase of the disease.
With the introduction of penicillin a gener-
ation ago, departments of “syphilology”
became as extinct and arcane as tech-
niques of cupping and bloodletting. But a recent
increase in the incidence of syphilis has been noted.1
Factors that may be contributory to this resurgence
include a depressed immune response in HIV-
infected individuals, and direct hematogenous in-
oculation among intravenous drug abusers.2 The
changes in epidemiology have rekindled a need for
awareness of the protean manifestations of syphilis.
Because cardiovascular (CV) syphilis represents a
tertiary stage, these lesions frequently fail to mani-
fest until 15 to 20 years after the initial infection.
Symptoms of CV syphilis can be detected in 3 to 15
percent of all untreated patients.3'9 Older literature
reported one-third of deaths due to syphilis were
secondary to its cardiovascular lesions.9
Syphilitic aortitis, the hallmark of CV syphilis, is
associated with a degeneration of the tunica media
by an inflammatory mesaortitis resulting in weak-
From the Division of Cardiothoracic Surgery, Newark
Beth Israel Medical Center, UMDNJ-New Jersey Medical
School, Department of Surgery, where Dr. McCullough
is a research fellow and Dr. Abel is a clinical professor,
Section of Cardiothoracic Surgery. This manuscript was
submitted in October 1989 and accepted in December
1989. Requests for reprints may be addressed to Dr.
McCullough, UMDNJ-New Jersey Medical School, MSB-
G506, 185 South Orange Avenue, Newark, NJ 07103.
ening of the arterial wall and aneurysmal dilata-
tion.10 The majority of syphilitic aortic aneurysms
involve the thoracic aorta with 63 percent in the
ascending portion, and 25 percent in the transverse
arch.11
CASE REPORT
A 37-year-old Haitian male was admitted to
UMDNJ-New Jersey Medical Center with a two-
week history of left arm pain, night sweats, and a
ten-pound weight loss. The patient resided in the
continental United States for the last seven years,
was married (his wife remaining in Haiti), and de-
nied homosexual activity or intravenous drug use.
He was afebrile. Blood pressure in the right arm was
130/90. The left arm was pulseless with a barely
detectable blood pressure. There were no Argyle-
Robinson pupils. The trachea was deviated to the
right. There was dullness to percussion in the left
upper lung field and a grade 1/6 short systolic
murmur was appreciated on precordial auscultation.
No focal neurological deficits were present.
Preliminary laboratory profile was unremarkable.
The admitting chest radiograph (Figure 1) sug-
gested a mediastinal mass causing tracheal devia-
tion. A computerized tomographic scan confirmed
the presence of a 4.5 cm aneurysm of the aortic arch
containing mural thrombus. Aortography demon-
strated a fusiform-saccular dilatation of the majority
VOL. 87— NUMBER 5 MAY 1990
409
of the thoracic aorta beginning just distal to the
aortic annulus, involving the entire arch and pro-
gressing to the mid-descending thoracic aorta (Fig-
ures 2A and 2B). The left subclavian artery was
occluded with retrograde filling from the left ver-
tebral. Additional laboratory investigation revealed
a positive serum VDRL and RPR. Cerebrospinal
fluid obtained from lumbar puncture was reactive in
both VDRL and FTA assays.
Because the underlying disease never had been
treated with antibiotics, we proceeded with a ten-
day course of intravenous penicillin followed by a
five-week course of intramuscular penicillin, deliver-
ing a total of 20,000,000 units. During this time, the
patient remained hospitalized, and continued to
complain of severe interscapular back pain relieved
only partially by leaning forward.
Figure 1. Admitting chest radiograph with superior mediastinal
mass resulting in displacement of the trachea to the right.
Following his course of antibiotics, the patient was
taken to the operating room for resection of the
aneurysm. Via a bilateral anterior thoracotomy in-
cision, total cardiopulmonary bypass was instituted
using left femoral and right atrial cannulation. At
19°C, a 34-minute period of circulatory arrest was
required to perform a distal anastomosis in the
middle of the descending thoracic aorta with a 34
mm woven low porosity Dacron® graft that previous-
ly had been autoclaved with 5 percent albumin solu-
tion. The left common carotid and innominate ar-
teries were attached to the graft as a “cuff.” The
chronically thrombosed left subclavian artery was
not grafted. The proximal anastomosis then was
completed approximately 3 cm distal to the plane
of the aortic valve where the remaining aorta ap- !
peared grossly normal.
The postoperative course was entirely uneventful.
After three years, the patient has remained
asymptomatic.
DISCUSSION
Despite the “magic bullet” of antibiotics, syphilis
still was listed as the third most commonly reported
communicable disease as late as 1980. 12 Less than 20
percent of syphilitic aortic aneurysms are assigned
an accurate clinical diagnosis prior to autopsy.4,613
Because a significant portion of the population con-
tinues to contract syphilis, and because CV syphilis
often defies antemortem diagnosis, the possibility of
syphilitic thoracic aneurysm must be borne in mind
during the evaluation of any anterior superior
mediastinal mass.5 The danger of delaying this
diagnosis was illustrated in a report of a presumably
malignant noncalcified anterior mediastinal mass
presenting with the superior vena caval syndrome.
Figures 2A and 2B. Aortograms showing a large thoracic aneurysm beginning just above the aortic annulus and involving the majority
of the thoracic aorta.
410
NEW JERSEY MEDICINE
The patient was treated emergently with radio-
therapy and corticosteroids but succumbed within
days of his admission. At autopsy, a syphilitic
aneurysm of his ascending aorta was found.1 2 3 4 5
The diagnosis of syphilitic aortitis is difficult and
only will be made if the possibility is considered.
Symptoms may include dysphagia, dyspnea, su-
perior vena caval syndrome, or hoarseness secondary
to impingement of the recurrent laryngeal nerve.9 * *
Positive serological testing supports the diagnosis,
but 15 to 30 percent of patients with syphilitic
aortitis will have negative serology.13 Aortic regurgi-
tation may be present but aneurysm now has re-
placed aortic insufficiency as the major complication
of syphilitic aortitis.13
In our patient, several controversial issues arose
as a treatment plan was devised. The delivery of
adequate preoperative antibiotic therapy to an ac-
tively infected patient requiring the placement of a
cardiovascular prosthesis was a paramount concern.
The current United States Public Health Service
guidelines for the antibiotic treatment of late CV or
neurosyphilis are benzathine penicillin (PCN) in-
tramuscularly for three weeks delivering a total dose
of 7.2 x 106 7 units or aqueous procaine PCN in-
tramuscularly for 15 days (9 x 106 units total dose).8
Persistent treponemas, however, have been noted in
arterial walls despite receipt of the recommended
therapy.8 In light of this, we chose a five-week
preoperative antibiotic regimen in an attempt to
sterilize the residual aorta. At least one case of acute
rupture of a syphilitic aneurysm attributed to a
Jarisch-Herxheimer reaction 19 hours following the
patient’s first dose of PCN has been reported,14 but
this is a very rare occurrence and should not temper
the use of vigorous preoperative antibiotic therapy.
There also are reports of patients who, because of
inaccurate preoperative diagnosis, received either no
antibiotic therapy, or postoperative therapy only.
There were not any unusual infectious complications
reported in these patients.15
The indications for surgical resection in this pa-
tient included evidence of compression of adjacent
mediastinal structures, and the imminent risk of
aneurysm rupture given the patient’s continued pain
suggesting unattenuated expansion. The technical
advances afforded by the technique of total
circulatory arrest enabled a one-stage resection of
this extensive aneurysm.1618
Finally, the possibility of a syphilitic aortic
aneurysm should be considered during the evalu-
ation of superior mediastinal masses. Since the signs
and symptoms are protean, and laboratory evidence
merely confirmatory, only a high index of suspicion
can lead to a proper diagnosis. Operative inter-
vention should not be delayed since the natural his-
tory usually includes lethal rupture six to eight
months following the onset of symptoms.9 Because
controlled studies indicating an ideal perioperative
antibiotic program have not been conducted, it ap-
pears reasonable to employ a conservative regimen
similar to that reported here in order to provide
adequate spirocheticidal effect prior to placement of
a prosthetic graft. ■
REFERENCES
1. Centers for Disease Control: Continuing increase in
infectious syphilis-United States. Leads from the MMWR.
JAMA 259:975-977, 1988.
2. Centers for Disease Control: Relationship of syphilis
to drug use and prostitution — Connecticut and Philadel-
phia, Pennsylvania. Arch Dermatol 125:169-170, 1989.
3. Phillips PL, Amberson JB, Libby DM: Syphilitic
aortic aneurysm presenting with the superior vena cava
syndrome. Am J Med 71:171-173, 1981.
4. Boharas S, Hollander L, Goldsmith M: The early
diagnosis of syphilitic aortitis. Am J Med Sci 203:54-64,
1942.
5. Welty JW: A necropsy survey of cardiovascular syph-
ilis with particular reference to its decreasing incidence.
Am J Med Sci 197:782-793, 1939.
6. Maynard EP: The present status of the diagnosis of
uncomplicated syphilitic aortitis. Bull NY Acad Med
18:383-391, 1942.
7. Martland HAS: Symposium on cardiovascular syph-
ilis. Am Heart J 6(1): 1-29, 1930.
8. Hoeprich PD (Ed.): Infectious Diseases — A Modern
Treatise of Infectious Processes. New York, NY, Harper
and Row, 1977, pp. 517-535.
9. Lande A, Berkmen YA: Aortitis-pathologic, clinical,
and arteriographic review. Radiol Clin North Am
14:219-240, 1976.
10. Cotran RS, Kumar V, Robbins SL (eds): Robbins
Pathologic Basis of Disease. Philadelphia, PA, W.B.
Saunders Company, 1989, pp. 368-371, 580-582.
11. Tadavarthy SM, Castaneda-Zuniga WR, Klugman
J, et al.: Syphilitic aneurysms of the innominate artery.
Radiology 139:31-34, 1981.
12. Davis BD, Dulbecco R, Eisen HN, Ginsberg HS
(eds): Microbiology. Philadelphia, PA, Harper and Row,
1980, pp. 752-758.
13. Heggtveit AH: Syphilitic aortitis — a clinicopath-
ologic autopsy study of 100 cases 1950-1960. Circulation
29:346-355, 1964.
14. Hughes GR: Jarisch-Herxheimer reaction and syph-
ilitic aortitis. Med J 1:360, 1968.
15. DuToit DF, McCormich M, Laker L: Syphilitic
aortitis — a case report. S Afr Med J 67:778-779, 1985.
16. Crepps JT, Allmendindger P, Ellison L, et al.:
Hypothermic circulatory arrest in the treatment of
thoracic aortic lesions. Ann Thorac Surg 43:644-647, 1987.
17. Crawford SE, Saleh SA: Transverse aortic arch
aneurysm-improved results of treatment employing new
modifications of aortic reconstruction and hypothermic
cerebral circulatory arrest. Ann Surg 194(2) : 180- 188, 1981.
18. Kazui T, Inoue N, Komatsu S: Surgical treatment
of aneurysms of the transverse aortic arch. J Cardiovasc
Surg 30:402-406, 1989.
VOL. 87— NUMBER 5 MAY 1990
411
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NEW JERSEY MEDICINE
Tuberculosis, AIDS,
and IV Drug Abuse
R.J. LAMB, PhD
l-TIEN YEH, MD
The number of tuberculosis cases reported has begun to rise. This rise in
the number of cases may be due to HIV infection, particularly among in-
travenous drug abusers.
Human immunodeficiency virus (HIV) infec-
tion is an increasing public health problem.
In New Jersey, intravenous drug users
(IVDUs) are at high risk for HIV infection. This
group accounts for about half of the acquired im-
munodeficiency syndrome (AIDS) cases in New Jer-
sey.1 The prevalence of HIV infection approaches or
exceeds half in IVDUs in some urban areas of north-
ern New Jersey; in other parts of the state the preva-
lence of HIV infection is lower, but not insignificant.
These individuals are at increased risk for op-
portunistic infections, including not only atypical
(nontuberculous) mycobacterial infections, but also
Mycobacterium tuberculosis infections.2 Tubercu-
losis among this group of individuals is thought to
be largely responsible for the reversal of the decades-
long decline in the prevalence of tuberculosis in the
United States.3 Because of the likelihood that tu-
berculosis will become an increasing public health
problem in New Jersey due to HIV infection, par-
ticularly among IVDUs, current literature on tu-
berculosis in HIV-infected individuals and IVDUs is
reviewed.
Dr. Lamb is affiliated with the Department of Psychiatry,
UMDNJ-SOM, Camden, and Dr. Yeh is affiliated with the
Department of Pathology and Laboratory Medicine, Uni-
versity of Pennsylvania School of Medicine, Philadelphia,
PA. This paper was submitted in October 1989 and ac-
cepted in November 1989. Requests for reprints may be
addressed to Dr. Lamb, UMDNJ-SOM, 401 Haddon Av-
enue, Camden, NJ 08103-1505.
Infection (clinically inactive) with M. tuberculosis
can cause a necrotizing disease (tuberculosis dis-
ease— active). Tuberculosis disease most often af-
fects the lungs, but lesions may occur in other organs
and may be disseminated throughout the body. Dis-
ease can occur shortly after infection (primary tu-
berculosis) or after a longer period of dormancy (re-
activation disease). The prevalence of tuberculosis
infection, as indicated by a positive tuberculin skin
test, is 7 to 8 percent nationwide, but can range up
to 20 to 30 percent in some localities. Of those in-
fected, 8 to 20 percent will develop tuberculosis dis-
ease. Progression from infection to disease generally
is prevented by a T-cell mediated immunological
response. This T-cell mediated immunity is respon-
sible for the positive tuberculin skin test seen in
individuals with tuberculosis infection.
The prevalence of tuberculosis infection among
IVDUs is similar to the local rate of infection.4 5 How-
ever, IVDUs are at an increased risk for the develop-
ment of tuberculosis disease.5 Further, the preva-
lence of tuberculosis infection is similar in IVDUs
with HIV infection and in those without, but IVDUs
with both HIV and tuberculosis infections are at
increased risk for the development of tuberculosis
disease as compared to IVDUs with only tuberculosis
infection.6 Finally, AIDS and AIDS-Related Com-
plex (ARC) patients who are IVDUs are more likely
to have tuberculosis disease than AIDS/ARC pa-
tients who are not IVDUs.78 Therefore, because of
their increased risk of progressing from tuberculosis
VOL. 87— NUMBER 5 MAY 1990
413
infection to disease, IVDUs should be screened for
tuberculosis infection and disease.
Several lines of evidence link HIV infection and
the rising prevalence of tuberculosis: since T-cell
mediated immunity is responsible for preventing the
progression from tuberculosis infection to disease,
anything that decreases T-cell mediated immunity
should increase the risk of tuberculosis disease; there
is geographic overlap between areas of rising tu-
berculosis and areas with a high prevalence of AIDS,
and further, higher-than-expected overlap is found
between registers of AIDS patients and tuberculosis
patients;912 patients with AIDS have a higher preva-
lence of tuberculosis than the general population,2 813
and patients with tuberculosis have a higher preva-
lence of AIDS and HIV infection than the general
population;14 and in a prospective study of tubercu-
losis infected individuals, those with concomitant
HIV infection were more likely to develop tubercu-
losis disease than those without concomitant HIV
infection.8 Interestingly, studies examining the over-
lap between the tuberculosis registers and the AIDS
registers indicate that AIDS patients who abuse in-
travenous drugs or are Haitian are more likely to
have tuberculosis disease than members of other
AIDS-risk groups.10111215 This finding may relate to
the lower socioeconomic status, poorer nutritional
status, and higher prevalence of tuberculosis infec-
tion compared to other AIDS risk groups.
Guidelines for tuberculosis screening have been
developed by the American Thoracic Society and the
Centers for Disease Control, which include the rec-
ommendation for screening of groups with a disease
rate in excess of the general U.S. population.16
IVDUs clearly are included in this recommendation.
An initial screen generally consists of a tuberculin
skin test, but should include a chest x-ray in pa-
tients with high-risk medical conditions, such as
AIDS patients, because of the high incidence of false
negative skin test results. For instance, in one study,
27 percent of the HIV seropositive individuals en-
rolled in a methadone maintenance program were
anergic;6 in a second study, only 2 of 29 patients with
both tuberculosis and AIDS had a positive tubercu-
lin skin test;8 finally, in a third study only 50 percent
of the patients with HIV infection and tuberculosis
disease had a positive tuberculin skin test.14 Thus,
anergy testing may be of value in tuberculosis
screening of IVDUs and other individuals at risk for
HIV infection.
Tuberculosis disease frequently has an atypical
presentation in HIV-infected individuals; for in-
stance, extrapulmonary tuberculosis disease is much
more common.7814 Because of the atypical presen-
tation in HIV-infected individuals, a high index of
suspicion must be present for the diagnosis of tu-
berculosis to be made. Definitive confirmation of the
diagnosis is made by the culture of M. tuberculosis
from body fluids or tissues, that may require numer-
ous attempts. Appropriate specimens include
sputum, blood, urine, bone marrow, and lymph
nodes, as well as any other clinically suspicious body
fluid or tissue.
Conversely, the presence of tuberculosis disease,
particularly if extrapulmonary, may indicate HIV
infection; this especially is the case for HIV infection
risk groups. Tuberculosis disease often presents
before other opportunistic infections in HIV-infected
individuals.8131417 Also, because of their increased
risk for developing tuberculosis disease, individuals
with HIV infection and tuberculosis infection should
receive prophylactic treatment with isoniazid. 18,19
Guidelines for the prophylactic treatment of tu-
berculosis infection in order to prevent the develop-
ment of tuberculosis disease have been developed by
the American Thoracic Society and the Centers for
Disease Control,18,20 and by the Committee on
Isoniazid Preventive Treatment.21 The latter speci-
fies that heroin addicts with positive tuberculin skin
tests should receive prophylactic treatment. The
typical prophylactic treatment is isoniazid, 300 mg
per day, for one year, unless infection with isoniazid
resistant organisms is suspected. When isoniazid is
used, pyridoxine also should be given, and monthly
clinical evaluations of the possibility of liver toxicity
made; in patients at high risk for liver toxicity, ap-
propriate laboratory testing should be done. Since
compliance is the major factor in unsuccessful
prophylactic treatment of tuberculosis, consider-
ation should be given to administering prophylactic
treatment to appropriate individuals in the drug
abuse treatment setting when attendance is daily
and long term, e.g. methadone maintenance clients.
The Committee on Isoniazid Preventive Treatment
lists six factors that should be considered before
initiating isoniazid prophylactic treatment: (1) ex-
clude the presence of tuberculosis disease; (2) ex-
clude individuals with prior adequate prophylactic
therapy; (3) exclude or exercise caution with individ-
uals with prior adverse reactions to isoniazid; (4)
defer therapy of those with unstable hepatic func-
tion; (5) consider interactions with other drugs or
hepatotoxic agents; and (6) if possible, defer treat-
ment of pregnant women.21
Guidelines for the treatment of tuberculosis dis-
ease have been developed by the American Thoracic
Society and the Centers for Disease Control.18'20 Sug-
gestions of high failure rates in AIDS patients
treated by a standard six-month regimen22 have led
to a recommendation for a minimum of nine months
of therapy using at least three active drugs, continu-
ing at least six months after the patient becomes
culture negative for M. tuberculosis . 18,19
One should note that rifampin accelerates the
414
NEW JERSEY MEDICINE
metabolism of many drugs including oral contracep-
tives23 and methadone,24 decreasing the effectiveness
of these drugs. These interactions do not contrain-
dicate the use of rifampin, but patients being treated
with rifampin should be made aware of these inter-
actions. Patients at risk for HIV infection or with
HIV infection should be counseled about the de-
sirability of using condoms as a means of birth con-
trol, in any case. Furthermore, patients who are
IVDUs and who are not in drug abuse treatment
should be encouraged to enter a treatment program
as soon as possible.
SUMMARY
Human immunodeficiency virus (HIV) infection
does not place individuals at risk for tuberculosis
infection, but rather places individuals with tuber-
culosis infection at increased risk for the develop-
ment of tuberculosis disease. Likewise, illicit in-
travenous drug use places individuals with tubercu-
losis infection at increased risk for tuberculosis dis-
ease, and intravenous drug users (IVDUs) who also
are HIV-infected are at further increased risk. In
areas or groups with high rates of tuberculosis infec-
tion, individuals at high risk for HIV infection are
candidates for tuberculosis screening and prophy-
lactic treatment with isoniazid. Because the users of
illicit intravenous drugs frequently come from com-
munities with a high prevalence of tuberculosis in-
fection and are at high risk for HIV infection in New
Jersey, IVDUs and former IVDUs should be screened
for tuberculosis infection, and if indicated (and not
contraindicated), should receive prophylactic treat-
ment with isoniazid.
In patients presenting with extrapulmonary tuber-
culosis disease, the possibility that this disease is an
early manifestation of HIV infection should be con-
sidered. ■
REFERENCES
1. New Jersey Department of Health: AIDS cases, State
of New Jersey as of August 31, 1989.
2. Selik RM, Starcher ET, Curran JW: Opportunistic
diseases reported in AIDS patients: Frequencies, associa-
tions, and trends. AIDS 1:175-182, 1987.
3. Centers for Disease Control: Tuberculosis — United
States, 1985 — and the possible impact of human T-
lymphotropic virus type IH/lymphadenopathy-associated
virus infection. MMWR 35:74-6, 1986.
4. Friedman LN, Sulivan GM, Bevilaqua RP, Loscos R:
Tuberculosis screening in alcoholics and drug addicts. Am
Rev Respir Dis 136:1168-1192, 1987.
5. Reichman LB, Felton CP, Edsall JR: Drug de-
pendence, a possible new risk factor for tuberculosis dis-
ease. Arch Intern Med 139:337-339, 1979.
6. Selwyn PA, Hartel D, Lewis VA, et al.: A prospective
study of the risk of tuberculosis among intravenous drug
users with human immunodeficiency virus infection. N
Engl J Med 320:545-550, 1989.
7. Handwerger S, Mildvan D, Senie R, McKinley FW:
Tuberculosis and the acquired immunodeficiency syn-
drome at a New York City hospital: 1978-1985. Chest
91:176-180, 1987.
8. Sunderman G, McDonald RJ, Maniatis T, et al.:
Tuberculosis as a manifestation of the acquired im-
munodeficiency syndrome (AIDS). JAMA 256:362-366,
1986.
9. Cole CH, Witte JJ, Bigler WJ, et al.: Tuberculosis
and acquired immunodeficiency syndrome — Florida.
MMWR 35:587-589, 1986.
10. Stoneburner RL, Milberg JA, Schultz S, et al.: Tu-
berculosis and acquired immunodeficiency syndrome —
New York City. MMWR 36:785-787, 1987.
1 1 . Hadler JL, Burger R: Tuberculosis and AIDS — Con-
necticut. MMWR 36:133-136, 1987.
12. Chaisson RE, Schecter GF, Theuer CP, et al.: Tu-
berculosis in patients with the acquired immunodeficiency
syndrome: Clinical features, responses to therapy, and
survival. Am Rev Respir Dis 136:570-574, 1987.
13. Maayan S, Wormser GP, Hewlett D, et al.: Ac-
quired immunodeficiency syndrome (AIDS) in an eco-
nomically disadvantaged population. Arch Intern Med
145:1607-1612, 1985.
14. Pitchenik AE, Burr J, Suarez M, et al.: Human T-
cell lymphotropic virus-III (HTLV-III) seropositivity and
related disease among 71 consecutive patients in whom
tuberculosis was diagnosed. Am Rev Respir Dis
135:875-879, 1987.
15. Pitchenik AE, Cole C, Russel BW, et al.: Tubercu-
losis, atypical mycobacteriosis, and the acquired im-
munodeficiency syndrome among Haitian and non-Hai-
tian patients in South Florida. Ann Intern Med
101:641-645, 1984.
16. American Thoracic Society and the Centers for Dis-
ease Control: Control of tuberculosis. Am Rev Respir Dis
128:336-342, 1983.
17. Louie E, Rice LB, Holzman RS: Tuberculosis in
non-Haitian patients with acquired immunodeficiency
syndrome. Chest 90:542-545, 1986.
18. American Thoracic Society and the Centers for Dis-
ease Control: Mycobacterioses and the acquired im-
munodeficiency syndrome. Am Rev Respir Dis
136:492-496, 1987.
19. Centers for Disease Control: Diagnosis and manage-
ment of mycobacterial infection and disease in persons
with human immunodeficiency virus infection. Ann Intern
Med 106:254-256, 1987.
20. American Thoracic Society and the Centers for Dis-
ease Control: Treatment of tuberculosis and tuberculosis
infection in adults and children. Am Rev Respir Dis
134:355-363, 1986.
21. Committee on Isoniazid Preventive Treatment: Pre-
ventive treatment of tuberculosis. Chest 87(2) suppl.
128S-132S, 1985.
22. Sunderam G, Mangura BT, Lombardo JM, Reich-
man LB: Failure of “optimal” four-drug short-course tu-
berculosis chemotherapy in a compliant patient with
human immunodeficiency virus. Am Rev Respir Dis
136:1475-1478, 1987.
23. Skolnick JL, Stoler BS, Katz DB, Anderson WH:
Rifampin, oral contraceptives, and pregnancy. JAMA
236:1382, 1976.
24. Kreek MJ, Garfield JW, Gutjahr CL, Giusti LM:
Rifampin-induced methadone withdrawal. N Engl J Med
294:1104-1106, 1976.
VOL. 87— NUMBER 5 MAY 1990
415
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416
NEW JERSEY MEDICINE
Minority Health Status
in New Jersey
GEORGE HAMPTON
DOUGLAS H. MORGAN
BILLIE SLAUGHTER, PhD
The health status of minorities in New Jersey, like that of the nation, continues
to lag far behind that of whites. In an effort to address this problem, UMDNJ
has established a Minority Health Institute to focus the resources of the
state’s academic health science center on the problem.
Health care delivery, financing, and effec-
tiveness for the urban poor and minorities
are becoming critical issues in the social
and economic realities of today. The need for well-
informed advocacy with respect to health trends and
practices that affect these populations never has
been greater. The University of Medicine and Den-
tistry of New Jersey (UMDNJ), through its Minority
Health Institute and Task Force, has addressed
these critical concerns, and it seeks to promote pro-
grams that assist in reducing the high morbidity and
mortality among the urban poor and minorities.
Recent studies have demonstrated the critical im-
portance of, and urgency for, immediate action
directed at reducing the marked disparities that
exist between the health profiles of America’s mi-
nority and non-minority populations. In the 1985
From UMDNJ-New Jersey Medical School, Mr. Hampton
is vice-president for urban and community affairs, Mr.
Morgan is executive director for the Minority Health In-
stitute, and Dr. Slaughter is director of educational de-
velopment at UMDNJ-School of Osteopathic Medicine.
Requests for reprints may be addressed to Mr. Hampton,
UMDNJ-Office of Urban and Community Affairs, 65
Bergen Street, Room 801, Newark, NJ 07107.
Report of the Secretary’s Task Force on Black and
Minority Health, excess deaths were cited as the
primary cause of the health profile disparity.1 “Ex-
cess deaths” is defined as the difference in those
deaths observed in the minority populations and the
number of deaths that would have been expected in
the minority population if they had the same age
and sex-specific death rate as the non-minority
population.1 Nationally, black and other minority
populations experience almost 60,000 excess deaths
per year.1 Cancer, cardiovascular disease and stroke,
cirrhosis, diabetes, homicides and accidents, and in-
fant mortality have been identified as the direct
contributors to the high mortality rate in these popu-
lations (Table).1
The secretary’s report provides detailed infor-
mation for each of the contributors on the poor
health status of minorities. For example, blacks
have twice the rate of infant mortality as whites, a
rate equal to or greater than the infant mortality rate
of many underdeveloped third-world nations.1 Over
the last 25 years, cancer mortality rates for blacks
increased by 26 percent while the increase for whites
has been only 5 percent.- The death rate from lung
cancer is 45 percent higher among black males than
VOL. 87— NUMBER 5 MAY 1990
417
white males. Homicide accounts for excess mortality
among blacks under the age of 45 — more than any
other cause except infant mortality and heart dis-
ease (Figure l).2 Over a lifetime, it is projected that
1 out of 21 black males will become a homicide
victim, compared to 1 out of 131 white males (Figure
2).:’ A more recent report, Health United States 1988,
released by the National Center for Health Statistics
of the United States Department of Health and
Human Services, indicated that white Americans
enjoy increased life expectancy resulting from de-
clining mortality and morbidity from major illness.
In contrast, black Americans are experiencing a de-
crease in life expectancy, due in part to the increas-
ing incidence of AIDS and homicides in the black
community.4 The health status of racial mi-
norities and the poor in New Jersey is similar to
that across the nation. The leading causes of death
among blacks in New Jersey in 1987 were heart
disease, cancer, infectious parasitic diseases,
cerebrovascular disease, AIDS, and accidents." The
incidence of AIDS in the state, however, differs dra-
matically from national trends. Although New Jer-
sey ranks fourth in the nation in the number of
reported AIDS cases, 55 percent of New Jersey’s
cases are linked to intravenous drug abuse (IVDA)
as the source of infection.6 Nationally, IVDA ac-
counts for only 20 percent of AIDS cases. Also, New
Jersey has the highest percentage of women with the
HIV infection and ranks third in the nation in the
number of pediatric AIDS cases.6 Fifty-six percent
of New Jersey’s cases occur in blacks and Hispanics.6
Recent information compiled by New Jersey’s
State Department of Health is consistent with the
earlier findings of the Secretary’s Task Force, name-
ly that minorities in New Jersey experience higher
rates of mortality and morbidity than do whites.7
The report, Health Profile: Black and Minority
Populations in New Jersey, issued by the New Jersey
State Department of Health, reveals the magnitude
of the health problems facing minorities in New Jer-
sey.7 Highlights of the report indicate the following:
The incidence of very low birth weight for whites
is 9.4 births per 1,000 in comparison to 27.5 births
per 1,000 for blacks. Risk of very low birth weight
(less than 1500 gm) is 2.9 times higher for black
infants than for white infants.
AIDS deaths among black infants are 14 times
greater than AIDS deaths among white infants.
Syphilis rates among black adults are 25 to 30 times
greater than syphilis death rates of white adults.
Homicide death rates among black adults are almost
four times greater than homicide death rates for
white adults. Esophageal cancer death rates among
black males are three times greater than esophageal
cancer death rates for white males. Chemical poison-
Black Males
< 45 Years
Total = 14,726
Black Males
< 70 Years
Total = 35,321
100
Homicide and Accidents
Infant Mortality
Heart Disease and Stroke
Cirrhosis
Cancer
Diabetes
All Other Causes
'The base of "zero" is equal to the mortality rate for whites. "Excess deaths” indicate those observed in excess of whites.
Report of the Secretary's Task Force on Black and Minority Health. United States Department of Health and Human Services, Volume
1. Executive Summary, page 72, 1985.
Figure 1. Average annual excess deaths for black males, 1979-1981.*
418
NEW JERSEY MEDICINE
ings among the employed black population are three
times greater than chemical poisonings for the em-
ployed white population. Cardiovascular mortality
rates, based on a three-year average, are higher for
nonwhite males than white males of age 45 to 64,
and higher for nonwhite females than white females
of the same age group.
These findings are devastating, particularly in
light of the tremendous advancements made in
medical science and technology. The findings clearly
indicate, however, that New Jersey’s minority popu-
lation has not benefited equally from these medical
advancements.
Concern about these issues, along with the need
for demonstrative action, has led UMDNJ to de-
velop the Minority Health Institute. UMDNJ estab-
lished the Minority Health Task Force (a group of
minority administrators and faculty within UMDNJ
and representing the University’s three campuses in
Newark, Piscataway/New Brunswick, and Stratford/
Camden) as the advisory body for the Institute.
Members of the Task Force represent major dis-
ciplines and specialties within medicine and den-
tistry, including adolescent medicine, pediatrics, ob-
stetrics and gynecology, mental health, dentistry,
and law.
The mission of the Minority Health Institute is to
analyze risk factors associated with preventable
morbidity and premature mortality among minority
and poor populations in New Jersey, and to develop
and recommend priorities for establishing demon-
strative interventions on those risk factors. In
furtherance of its mission, the Institute will conduct
or sponsor research of those problems that directly
affect minority health status, compile and maintain
a central database of information concerning mi-
nority health; and advocate for and conduct health
education and outreach efforts concerning minority
health issues. The Institute will disseminate the re-
sults of its findings to public policymakers, state and
local health and social services agencies, national
health professionals and organizations, and the com-
munity. It is UMDNJ’s hope that the Institute will
be viewed as a creditable source of information re-
garding minority health, and as a vehicle to assist
in the development of appropriate health care pro-
grams.
SUMMARY
Although advances in biomedical science and
technology have resulted in increased life expectan-
cy for whites, minorities in the United States and
Deaths per 100,000 Population
White Black Native Asian/ White Black Native Asian/
American Pacific American Pacific
Islander Islander
‘Death rates for hispanics are not available. Death rates for native Americans and Asian/Pacific Islanders probably are underestimated
due to less frequent reporting of these races on death certificates as compared with the census.
Report of the Secretary’s Task Force on Black and Minority Health. United States Department of Health and Human Services, Volume
1. Executive Summary, page 159.
Figure 2. Average annual age-adjusted death rates for homicide for persons under 45 years of age, 1979-1981.*
VOL. 87— NUMBER 5 MAY 1990
419
Table. Average annual total and excess deaths in blacks, selected causes of
mortality, United States, 1979-1981*
Excess
Males and
Cumulative
Deaths
Females
to Age 45
Excess Deaths
Males and Females
Cumulative to Age 70
Number
Percent
Number
Percent
Causes of Excess Death
Heart Disease and Stroke
3,312
14.4
18,181
30.8
Homicide and Accidents
8,041
35.1
10,909
18.5
Cancer
874
3.8
8,118
13.8
Infant Mortality
6,178
26.9
6,178
10.5
Cirrhosis
1,121
4.9
2,154
3.7
Diabetes
223
1.0
1,850
3.1
Subtotal
19,749
86.1
47,390
80.4
All Other Causes
3,187
13.9
11,552
19.6
Total Excess Deaths
22,936
100.0
58,942
100.0
Total Deaths, All Causes
48,323
138,635
Ratio of Excess Deaths to
Total Deaths
47.4%
42.5%
Percent Contribution of
Six Causes to Excess Death
86.1%
80.4%
* Report of the Secretary’s Task Force on Black and Minority Health. United States Depart-
ment of Health and Human Services. Volume 1, Executive Summary, Page 5, 1985.
in New Jersey have not received equal benefit. The
establishment of the UMDNJ-Minority Health In-
stitute is a critical step toward understanding and
ameliorating the disparity in health status between
minority and non-minority populations in New Jer-
sey. The location of the Institute within the state’s
academic health science center is appropriate and
reflects UMDNJ’s commitment to the resolution of
factors that have contributed to the poor health
status of minorities in New Jersey.
Editor’s Comment. The concerns expressed in
this paper were echoed by Louis Sullivan, MD, sec-
retary of Health and Human Services. In his keynote
address to the 1989 Annual Meeting of the American
Public Health Association, he said, “Minority
health status is on a slippery slope, and there are
no secure footholds.’’ He emphasized the points enu-
merated by the authors and pointed out that blacks
have less access to care, regardless of income. We
hope the LIMDNJ-Minority Health Institute can
play a significant role in narrowing the gap between
different tiers of health care. The Bush adminis-
tration has resolved to do its part. ■ HDS
REFERENCES
1. Department of Health and Human Services
(DHHS): Report of the Secretary’s Task Force on Black
and Minority Health, Volume I. Executive Summary.
Washington, DC, August 1985.
2. Davis HM: Our People are Dying , Blacks in New
Jersey 9th Annual Report. New Jersey Public Policy Re-
search Institute, September 1989.
3. United States Department of Justice: The Risk of
Violent Crime. Washington, DC, May 1985.
4. The New York Times: Life expectancy rates widen
over racial lines. March 16, 1989.
5. Center for Health Statistics, New Jersey State De-
partment of Health: personal communication.
6. New Jersey State Department of Health, Division of
AIDS Prevention and Control: Monthly statistics report.
Trenton, New Jersey, May 31, 1989.
7. New Jersey State Department of Health, Preliminary
Report Health Profile: Black and Minority Populations in
New Jersey, Trenton, New Jersey, June 1989.
420
NEW JERSEY MEDICINE
SPECIAL FEATURE
Professional Medical
Conduct Reform Bill
MICHAEL B. GROSSMAN, DO
This new law closes the many loopholes in the previous statute. Physicians
should review the entire law; it is readable and fairly understandable.
On his last working day in office, Governor
Thomas Kean signed the Professional
Medical Conduct Reform Bill into law. The
bill was originally Senate Bill 2936 (see page 385)
and was sponsored by Senator Richard Codey.
Passage of this bill will move medical discipline
forward in the state of New Jersey. This current
legislation makes a contribution to ensuring New
Jersey citizens the high quality of care they have
expected of physicians. I believe all New Jersey
physicians interested in quality of care will applaud
this new law.
Dr. Grossman is president of the State Board of Medical
Examiners (SBME). Correspondence may be addressed
to Dr. Grossman, SBME, 28 West State Street, Trenton,
NJ 08608.
THE OLD LAW
This law closes the many loopholes in the previous
statute that required hospitals to report all reduc-
tion of privileges by their staff members. Under the
old law, those reports were not required to be filed
until the governing board of the hospital approved
the action. Sometimes many years passed and in
many more instances the governing board never took
an action so there was no report. Many conscientious
physicians who were concerned about their problem
colleagues were frustrated in their attempts to do
their jobs as chiefs of service and department chair-
men.
THE NEW LAW
The new law requires the reporting to occur within
seven days from the institution of the action with
VOL. 87— NUMBER 5 MAY 1990
421
SPECIAL FEATURE
or without approval by the governing body. All types
of actions including those undertaken voluntarily
and involuntarily and those mandatory supervision
and requirements for consultation are to be reported.
Reporting a physician whose privileges have been
reduced does not necessarily mean that he will be
disciplined nor does it necessarily mean that he will
lose his license. It is the intention of the Board to
attempt to identify physicians whose skills have de-
teriorated and to direct them into a re-education
a month, if not more often. The Board is looking
forward to having another group of informed individ-
uals to participate in the review and regulation pro-
cess, making recommendations as to appropriate ac-
tion.
LEGAL PROTECTION
The new law provides that Board members, em-
ployees of the Board, and consultants to the Board
shall be provided with legal counsel by the attorney
general and also shall be indemnified by the state
The Board feels strongly that physicians who are aware of impaired and/or
incompetent colleagues now have a legal as well as a moral requirement to report
to the Board, and the Board will expect that to occur appropriately.
process if possible. Of course, the more egregious
cases probably will require some form of discipline.
Another major reform included in the new law is
the requirement that physicians report their col-
leagues who could represent a danger to patients.
This is the first time in New Jersey that physicians
have a legal requirement to inform the Board about
their colleagues. That report must be forthcoming if
they are in possession of information that another
physician either is impaired or incompetent in such
a fashion that patients could be at risk. It does not
require that the reporter wait until a patient has
been harmed but only that a patient could be in
danger. Exempted from that requirement are phy-
sicians who become aware of impairments by virture
of being a treating physician. That particular arena
of doctor/patient confidentiality is appropriately
protected by this law. However, the Board feels
strongly that physicians who are aware of impaired
and/or incompetent colleagues now have a legal as
well as a moral requirement to report to the Board,
and we will expect that to occur appropriately.
PRACTITIONER REVIEW PANEL
The law creates a practitioner review panel that
will be comprised of three physicians, three public
members, a hospital administrator, a government
representative, and a member of the Board. The
member of the Board may not be chairman of the
panel and will not be able to vote on any matters
before the Board that have been reviewed by the
panel. This panel is to receive all reports of settled
or adjudicated malpractice actions. There no longer
is a monetary threshold. For the first time, insurance
companies will be required to report to the Board
those physicians whose malpractice insurance is
cancelled or upon whom a surcharge is levied. The
panel also would receive reports of reduction in hos-
pital privileges. I anticipate that the panel would be
a very hardworking group meeting at least a full day
of New Jersey for good faith work in that capacity.
It also provides excellent immunity for good faith
reporting in the colleague reporting section. Ad-
ditionally, there is good protection for the peer re-
view process.
MEDICAL DIRECTOR
Additionally, a fulltime medical director who has
knowledge of chemical dependency is mandated.
The Board has been looking for someone prior to the
passage of this law and continues its search. Ad-
ditionally, the commissioner of health now has a seat
on the Board.
OTHER ASPECTS OF THE LAW
There are a number of other important aspects of
the statute beyond the scope of this article. I would
suggest that all physicians may want to request a
copy of the law itself. It is readable and fairly under-
standable. The Board of Medical Examiners plans
to host a seminar to review S-2936 with interested
parties including physicians, medical directors, and
chiefs of services.
CONCLUSION
As stated in the beginning of the article, it is the
opinion of the State Board of Medical Examiners
that this new law represents a positive step forward
in regulation in the state of New Jersey. The Medical
Society of New Jersey was an important participant
in the formulation of this law. I believe the desires
of the Medical Society were about 90 percent satis-
fied by the final compromise draft. I believe the
desires of the State Board of Medical Examiners also
were satisfied about 90 percent. For the first time,
it appears to me we have good legislation that will
make the identification of impaired and incompe-
tent doctors easier, the reporting to the regulators
more protected, and the disciplinary process more
efficient, and that is as it should be. ■
422
NEW JERSEY MEDICINE
NOTEBOOK
■ TRUSTEES’ REPORT ■
A regular meeting of the Board
of Trustees was held on March 18,
1990, at the executive offices in
Lawrenceville. Detailed minutes
are on file with the secretary of
your county society. A summary of
significant actions follows:
Report of the President . . .
(1) New Appointments , . . An-
nounced appointments of Karl T.
Franzoni, MD, as Speaker of the
House of Delegates, and of Frances
J. Dunston, MD, MPH, as Com-
missioner of Health.
(2) Medicare Reimbursement on
Unassigned Claims . . . Referred
to the AMA delegation for con-
sideration a letter from Michael
Bernstein, MD, president of the
Passaic County Medical Society,
suggesting that the resolution to be
submitted to the AMA (opposing
the new Medicare law requiring
physicians to file claim forms for
patients) be modified to request
that, in the event the requirement
is not rescinded, the Health Care
Financing Administration reim-
burse physicians for the added ex-
pense of filing claim forms.
(3) Automobile Insurance Re-
form Act of 1990 (No-Fault) (A-l;
S-2295) . . . Heard from Mr.
Maressa that there would be no
amendments to this bill unless the
governor personally approved
them; hence, Mr. Maressa felt no
purpose was served by appearing
at the remaining public hearing.
(4) Membership in JEMPAC , . ,
Reiterated the Board’s request
that county medical societies urge
members of executive committees
to join JEMPAC in 1990. Also, was
advised that JEMPAC is a politi-
cal action committee and its legal
purpose is to raise money for con-
tributions to legislators; it does not
lobby.
(5) AMA Leadership Conference
. . . Noted record attendance at
the AMA’s National Leadership
Conference and that the AMA
search committee is ready to ac-
cept applications for the position
of executive vice-president of the
AMA, created by the resignation of
James H. Sammons, MD.
(6) Tillinghast Report . . . Men-
tioned that a review of the Medical
Inter-Insurance Exchange of New
Jersey claims administration was
performed by an outside consul-
tant, Tillinghast.
(7) Retiring Board Members . . .
Stated that retiring Board mem-
bers (Drs. Formica, Robinson,
Yood, and Zawadsky, and Ms.
Goldie, student member) will be
given the opportunity to make
statements at the next Board
meeting, if they so desire.
Report of Executive Director . . .
(1) Paid Memberships . . . Noted
MSNJ paid memberships as of
February 28, 1990, totaled 6,037,
and heard that it appears likely
that as of March 17, 1990, total
paid memberships will match or
possibly exceed the 1989 total.
(2) MSNJ Financial Statements
. . . Reviewed and approved the
financial statements for the period
ending January 31, 1990.
(3) Legislation . . . Noted the fol-
lowing four items: No-Fault A-l
. . . Unanimously approved the
initiation of litigation on the con-
stitutionality of the annual tax of
physicians’ licenses and the ban on
balance billing; Living Will Coali-
tion . . . Concurred with the rec-
ommendations that MSNJ partici-
pate in the Living Will Coalition
but not underwrite the special
budgetary project; Commissioner
of Health (S-642) . . . Agreed not to
list this bill (to delete the require-
ment of a medical license to be
commissioner of health) for a vote
at this time as it is inappropriate
since the new commissioner of
health is a medical doctor; and,
Optometric Use of Drugs (A- 743)
. . . Noted that MSNJ is actively
opposed to A-743 and that county
medical societies and MSNJ have
contacted appropriate legislators.
(4) Litigation . . . Noted the fol-
lowing items: MSNJ versus Merin
. . . Noted that there has been no
response to MSNJ’s request for a
motion to stay implementation of
the commissioner’s surcharge rule,
and noted that penalty for not pay-
ing the surcharge would be can-
cellation of a physician’s pro-
fessional insurance policy; State
Board of Medical Examiners ver-
sus Sinha . . . Noted MSNJ has
entered this case amicus (this case
involves the supervision of a
certified nurse anesthetist by an
anesthesiologist) and the opinion
of the court is pending; Subpoena
of Physician Records by State
Board of Medical Examiners
(SBME) . . . Mentioned that this
case involves a significant develop-
ment, since subpoenas issued by
SBME now are challengeable, and
when challenged will be referred to
a trial judge for development of a
record; and, PRO versus Diaz . . .
Noted that The PRO of New Jer-
sey, Inc. cited Doctor Diaz for gross
and flagrant violation and rec-
VOL. 87— NUMBER 5 MAY 1990
423
ommended removal from the
Medicare program and the case
was appealed and the decision was
modified: Dr. Diaz will continue
with the program, but his actions
will be monitored.
UMDNJ Report . . . Received a
report from Paul F. Larson, MD,
noting the decrease in appropria-
tions for UMDNJ due to the
budget cuts and that this will
create a reduction in the work
force, and that estimates of the tax
increase for institutions of higher
education will restrict further the
funds of UMDNJ. Also, noted that
new research at UMDNJ disclosed
a hidden antibody occurring in
some patients with Lyme disease.
NJ Hospital Association . . . Re-
ceived a report from Louis P.
Scibetta, noting the upcoming NJ
Hospital Association Annual
Meeting and litigation initiated by
the New Jersey public advocate
challenging a proposed nongroup
rate increase resulting in a decision
against Blue Cross.
Committee on Conservation of
Vision . . . Approved the follow-
ing:
That the 1990 Eye Health Screening
Program be held the week of Septem-
ber 24, 1990.
Physicians’ Health Program . . .
Approved the following:
That the MSNJ Board of Trustees ac-
cept the budget proposed by the Board
of Directors of the Physicians’ Health
Program.
Task Force on the Shortage of
Nurses and Technical Personnel
. . . Unanimously approved the
following:
That the Medical Society of New Jer-
sey endorse the education mobility
concept in nursing, i.e. from the nurs-
ing assistant through the various levels
of nursing education.
Also, noted that the Task Force
will place greater emphasis on the
allied health field, also crippled by
shortages. In addition, indicated
that Dr. Formica is MSNJ’s rep-
resentative on the Department of
Health’s Nursing Advisory Com-
mittee and Dr. Madara will serve
as the alternate representative.
Task Force on Patient Care for
the Under-Insured . . . Referred
the following to the Committee on
Medicaid:
That an immediate study be under-
taken by MSNJ to bring about
changes in current Medicaid law for
the purpose of addressing the issue of
uncompensated care.
Also, approved the following rec-
ommendation:
That the Uncompensated Care Trust
Fund compensation for benefits be ex-
panded to cover physician services.
In addition, defeated the following
recommendation:
That the mechanism of payment for
services under the Uncompensated
Care Trust Fund be administered via
a hospital-created intermediary con-
cept.
Finally, approved the following
recommendation:
That the MSNJ Task Force on Patient
Care for the Under-Insured become
part of a Blue Ribbon Task Force com-
posed of representatives from the New
Jersey Hospital Association, the New
Jersey Department of Health, the New
Jersey Department of Health and
Human Services, the Division of Medi-
caid, and members of the industry and
the Legislature, to meet the challenge
of providing patient care for the under-
insured.
Unfinished Business . . .
(1) AIDS Act of 1989 ... En-
dorsed the proposed legislation (es-
tablishing certain eligibility re-
quirements in the program of
grants to the states for counseling
and testing with respect to AIDS
and for other purposes) and
directed that Congressman Dan-
nemeyer be so advised.
(2) Physician Assistants . . .
Voted to continue to participate in
the Task Force hearings; however,
MSNJ efforts will concentrate on
keeping the pilot program within
responsible parameters.
New Business . . . Approved the
request to provide a letter of sup-
port for a grant application to con-
duct statewide diabetes activities
as requested by the New Jersey
State Department of Health, Dia-
betes Control Program. □
■■UMDNJ NOTES ■■
The University of Medicine and
Dentistry of New Jersey (UMDNJ)
dedicated a $4.5 million Clinical
Research Center that will provide
state-of-the-art patient rooms and
analytic laboratories for testing
new drugs, biomedical devices,
and medical therapies. Studies at
the Center will support and
enhance strong medical school re-
search programs in heart disease,
rheumatology, diabetes, and repro-
ductive endocrinology.
The surprise birth of a pygmy
mouse from a genetically altered
egg could be the first step in iden-
tifying the cause of — and possibly
treatment for — some human
growth abnormalities. Scientists at
UMDNJ-Robert Wood Johnson
Medical School, Piscataway, were
breeding mouse lines to study ge-
netic mutations when the tiny
mouse turned up. The mice could
be a model for studying growth ab-
normalities such as human dwarf
syndrome. They also may provide
a greater understanding of the
pathways involved in growth and
development. Twenty-five percent
of the patients who visit en-
docrinology clinics nationwide
have a growth abnormality.
The cause of Alzheimer’s disease
is associated with a decrease in the
amount of a protein hypothesized
to regulate the level of free calcium
in brain cells, according to re-
search conducted at UMDNJ-New
Jersey Dental School and
UMDNJ-Graduate School of
Biomedical Sciences, Newark.
424
NEW JERSEY MEDICINE
The studies show that Alz-
heimer’s patients have markedly
decreased levels of the calcium-
bonding protein, Calbindin-D28k,
that may regulate the amount of
calcium allowed to accumulate in
the nerve cells of the brain.
Without adequate amounts of this
protein, calcium slowly accumu-
lates, reaches toxic levels, and kills
the cells. The research is led by Dr.
Sylvia Christakos, associate
professor of biochemistry, and Dr.
Anthony Iacopino, a postgraduate
fellow.
Some patients with heart prob-
lems are swallowing an ultrasound
probe so our UMDNJ cardiologist
can examine parts of the heart un-
able to be seen by traditional
methods. More than 50 patients
have been diagnosed at Robert
Wood Johnson University Hospi-
tal, New Brunswick, with this
technique that allows detailed ob-
servation of the heart. The ultra-
sound probe is inserted in the
esophagus, the canal in the throat
that carries food to the stomach.
The back of the heart is flush
against the esophagus, so this
“back-door” approach allows doc-
tors to get clear color pictures of
that side of the beating heart.
Dr. Daniel Shindler, director of
cardiac ultrasound at UMDNJ-
Robert Wood Johnson Medical
School, is one of only a few phy-
sicians doing the procedure in the
state. Dr. Shindler inserts the
probe, attached to a tube, down
the patient’s throat. The patient is
awake but sedated and the throat
is sprayed with a local anesthetic.
The procedure usually takes about
15 minutes. Two-thirds of the pa-
tients examined were treated as
outpatients, with no hospital stay
required.
A comprehensive Microsurgery
Center — with services ranging
from emergency finger reattach-
ment to the repair of skin defects —
has been initiated at UMDNJ-
Robert Wood Johnson Medical
School, New Brunswick. It is the
first of its kind in central New Jer-
sey. The unit, a collaborative effort
with Robert Wood Johnson Uni-
versity Hospital, comprises three
microsurgeons, nurses, physical
therapists, and occupational ther-
apists. In addition to the surgical
services, this team provides
presurgical counseling in non-
emergencies and complete post-
operative care.
New programs to diagnose and
treat breast cancer, including a
screening center for women at high
risk, are part of the new Division
of Comprehensive Breast Services
at UMDNJ-Robert Wood Johnson
Medical School, New Brunswick.
The new screening center is offer-
ing services to women who are at
high risk of contracting breast
cancer, especially those who have
a history of breast disease in their
family. The center offers counsel-
ing, physical examinations, and in-
struction in self-examination.
A special surgical technique
used to remove certain skin
cancers while preserving healthy
tissue is available for the first time
at UMDNJ-Robert Wood Johnson
Medical School, New Brunswick.
The method is used primarily to
treat two types of malignancies in
the outer layer of the skin: basal
and squamous cell cancers. Called
Mohs micrographic surgery, after
Dr. Frederic Mohs, the surgeon
who developed it in the 1930s, the
procedure has been modified in a
number of ways that include tech-
nical improvements.
Dr. Michael Auletta, a
dermatologic surgeon, introduced
the procedure to UMDNJ. □
Stanley S. Bergen, Jr, MD
■■ MSNJ AUXILIARY ■■
In the January 1974 Shingle,
MSNJ executive director, Vincent
A. Maressa wrote, “The Auxiliary
can and should become an ex-
tension of the Medical Society of
New Jersey in the fields of legis-
lation and public relations.” He
added that the Auxiliary should
“continue to provide community
service and public relations pro-
grams and assist us with ours.”
Sixteen years later, the Aux-
iliary continues to do just that.
Through representation on state
and county medical society ex-
ecutive boards and committees,
auxiliary members have become
aware of the Society’s goals and
programs, and have offered as-
sistance in their implementation.
Across the state, county auxiliaries
and medical societies have joined
forces to address legislative con-
cerns. Together they have or-
ganized physician voter regis-
tration drives and encouraged
medical families to vote for can-
didates who support sound medi-
cal legislation, and lobbied vigor-
ously for the introduction of con-
structive health legislation and the
defeat of undesirable bills.
In 1989 to 1990, auxiliary mem-
bers nationwide participated in
phone blitz operations, letter writ-
ing campaigns, and visits to law-
makers’ offices to protest ETs;
worked successfully to ban smok-
ing on all domestic flights;
protested medical waste regis-
tration fees levied on New Jersey
physicians by the Department of
Environmental Protection; and
supported initiatives to introduce
legislation mandating more
stringent penalties for drunken
driving on New Jersey waterways.
Most importantly, however, the
Auxiliary spent the year continu-
ing to promote good will in the
community by raising thousands of
dollars for nursing scholarships,
health career grants, and other
philanthropic endeavors such as
the Heart Association, the Ameri-
can Cancer Society, and various
mental health and drug prevention
groups.
County auxiliaries also spon-
sored health education projects
and activities aimed at both im-
proving the lives of people in the
community and enhancing the
public’s image of medicine and the
medical family. Programs covered
a wide range of topics: seminars for
VOL. 87— NUMBER 5 MAY 1990
425
teachers and coaches on the abuse
of anabolic steroids and the use of
safety helmets to prevent head in-
juries; multilingual sessions to
teach teenagers proper babysitting
skills; high school health education
days; and the distribution of infant
car seats. In addition, there were
eye screenings, cholesterol checks,
sun screenings, food/clothing
drives for the homeless and needy,
and an “Adopt-A-Nursing Home”
project in which auxiliary mem-
bers visit residents and provide
them with special request items.
Finally, county auxiliary mem-
bers celebrated National Doctors’
Day. Poster contests were held in
many schools and the artwork, de-
picting how doctors serve people in
the community, was displayed in
hospital lobbies, shop windows,
and office buildings. Auxiliary
members personally recognized
physicians by presenting them
with red carnations and sending
messages of appreciation: “More
than anyone else we know how
hard you work; the long hours and
pressures you endure; and how
much you really care. Happy Doc-
tors’ Day.” □ Marion H. Geib
Hi NEW MEMBERS WKM
The Medical Society of New Jer-
sey would like to welcome the fol-
lowing new members:
Atlantic County
Michelle M. Battistini, MD
Marc D. Feldman, MD
Mahesh Ghayal, MD
Steven J. Giamporcaro, MD
Stuart J. Goldman, MD
Scott R. Kaneff, MD
Philip W. Mercer, MD
Yatish B. Merchant, MD
Donald P. Mitrane, MD
Alexander Onopchenko, MD
Jack Shakarshy, MD
Benjamin L. Co, MD
Roger A. Coven, MD
Shanti Dhupar, MD
John A. DiLullo, MD
Amina Elkassir, MD
James W. Geuder, MD
Michael L. Gross, MD
Russell J. Horn, MD
Chee Gap Kim, MD
Evan G. Kushner, MD
Glenn R. Leslie, DO
Joanne Leslie, MD
Lancaster Lo, MD
Jay Meyerowitz, MD
Anne J. Miller-Breslow, MD
Margaret M. Moogan, MD
John F. Nitti, MD
Andrew L. Pecora, MD
Joseph A. Rizzo, MD
Lois P. Robinson, MD
Constantine Rossakis, MD
Mark D. Schlesinger, MD
Eric D. Somberg, MD
Mary Swajian, DO
Burlington County
Neil H. Dorfman, MD
Martha B. Howard, MD
Pamela F. LeDeaux, MD
John A. Volpe, DO
Samuel H. Wasser, MD
Camden County
Carmen I. Barres, MD
Steven S. Baumgarten, MD
Simcha Cipkin, MD
William deLaRosa, DO
Adam B. Elfant, MD
Stuart C. Finch, MD
Karen L. Fung, MD
Christopher D. Koprowski, MD
John J. Litz, MD
Martha S. Matthews, MD
Cheryl M. Mitchell, MD
Jayesh P. Patel, MD
Charles E. Rawlings, III, MD
David B. Soil, MD
Eric D. Strauss, MD
William Tham, MD
Thomas V. Whalen, MD
David S. Zalut, MD
Cumberland County
Michael L. Anderson, MD
Bergen County
Howard M. Baruch, MD
Brian J. Bauer, MD
Alexander Biener, MD
Nicholas G. Bonvicino, MD
Laura E. Brenner, MD
Frank M. Candido, MD
Michael E. Casser, MD
Essex County
Fred M. Aueron, MD
William A. Christiana, MD
Mark S. Cukierman, MD
Keith E. Fraser, MD
Senthamarai Gandhi, MD
Howard A. Holtz, MD
Stefanie S. Jacobs, MD
Jonathan Kiev, MD
Deana M. Lazaro, MD
Robert D. Mills, DO
Shamkant P. Mulgaonkar, MD
Arnold D. Paulino, MD
Michael Schulder, MD
Loreta M. Uy, MD
Gloucester County
Vivian Vega, MD
Hudson County
James J. Cadden, MD
Anthony G. Del Piano, MD
Luis A. Gonzalez, MD
Frances B. Pelliccia, MD
Kothalanka S. Ramakrishna, MD
Nicholas P. Scarpa, MD
Hunterdon County
Patrick M. Collalto, MD
Shelley E. Justa, MD
Mercer County
Margaret M. Barnes, MD
Joaquin J. Cantillo, MD
Daniel J. Cohen, MD
Joseph M. DellaCroce, MD
KiritkumarT. Desai, MD
Richard E. Dixon, MD
Dorothea J. Drayer, MD
Gerard D. Fritz, MD
Michael E. Goldberg, MD
John A. Harman, MD
Richard T. Magrini, MD
Cynthia Matossian, MD
Jeffrey A. Mattes, MD
James M. O’Mara, MD
Jay R. Poliner, MD
Donald P. Rosen, MD
Theodore E. Spiro, MD
Arleen S. Zabell, MD
Middlesex County
Larry J. Cohen, MD
Howard N. Garson, MD
Robert R. Goodman, MD
Michael A. Healy, MD
Suzanne M. Kabis, MD
Steven J. Levin, MD
William J. Lowe, III, MD
Rohitkumar I. Shah, MD
Michael J. Simon, MD
Manuel R. Tan, MD
Lawrence N. Tanenbaum, MD
Louis Tsarouhas, MD
Irene L. Wapnir, MD
Monmouth County
Joseph Cohen, MD
Miguel Damien, MD
Paul Gennaro, MD
Peter T. Hetzler, MD
426
NEW JERSEY MEDICINE
Stephen A. Kardos, DO
Debra M. Ray, MD
Neal Ruda, MD
Morris County
Eric J. Benvenuti, MD
Herbert C. Conaway, Jr, MD
Vincent J. Emiliani, MD
James M. Fattu, MD
Matthew D. Iammatteo, MD
Vina H. Isaac, MD
Juan F. Lopez, MD
John R. McCormick, MD
Winston C. Moy, MD
Richard M. Neibart, MD
Jerry L. Pinkerton, MD
Mark A. Rieger, MD
Kathleen T. Ruddy, MD
John T. Truman, MD
Ocean County
Jospeh A. Casadonte, MD
Clint C. Ferenz, MD
Rami E. Geffner, MD
Neal D. Gittleman, MD
John Infantolino, MD
Rosanne Lamia, MD
Jeffrey M. Lipper, MD
Lawrence J. Schaefer, MD
Beatrice A. Symchowicz, MD
Passaic County
Mildred D. Agres, MD
Gail J. Anderson, MD
Michael F. Ardito, MD
Avrill R. Berkman, MD
Sylvia A. Coscia, MD
Oksana M. Demediuk, MD
John J. Doerr, MD
Ai R. Lee, MD
Kannan Ramamurthy, MD
Klaus Schreiber, MD
Joseph A. Silvano, MD
Ramasamy Swaminathan, MD
Chellappan Vijayakumar, MD
Somerset County
Anne M. Dubosky, DO
Ruby A. Halper-Erkkila, MD
Sussex County
Edward F. Babb, MD
Richard T. Bernstine, MD
Eugene Chin, MD
Stephen P. Landauer, MD
Daniel C. Monahan, MD
Union County
Lynne J. Acierno, MD
Michael B. Alexander, MD
Stephanie L. Arlis-Mayor, MD
Emir V. Duany, MD
Eli D. Finkelstein, MD
Stephen Gal, MD
John T. Gianis, MD
Todd P. Krell, MD
Donald A. Leichter, MD
Elzbieta E.K. Ostromecki, MD
Michael M. Plate, MD
Ricardo E. Rodriguez, MD
Scott D. Schoifet, MD
Albert L. Strunk, MD
Dulce Suapengco-Samonte, MD
Anthony J. Tarasenko, MD
Rita M. Watson, MD
■■PLACEMENT FILE ■■
The following physicians have
written to the Executive Offices of
MSNJ seeking information on op-
portunities for practice in New Jer-
sey. The information listed below
has been supplied by the physi-
cians. If you are interested in any
further information, please contact
the physicians.
GENERAL PRACTICE
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Also, internal medicine. Available.
Randi Silverbrook, DO, 3024 Wistar
Ct., Bensalem, PA 19020. College of
Osteopathic Medicine 1985. Partner-
ship or group. July 1990.
INTERNAL MEDICINE
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Also, general practice. Available.
David D. Gross, MD, 1045 Liberty St.,
Apt. 1, Trenton, NJ 08611. St.
George’s (Grenada) 1987. Board eli-
gible. Available August 1990.
Marc Kesselhaut, MD, 1 Rustic Ridge,
C16, Little Falls, NJ 07424. St.
George’s 1986. Board eligible. Solo or
partnership in Mercer, Somerset, Bur-
lington, Hunterdon, or Middlesex
counties. Available September 1990.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner-
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital-based. Available
July 1990.
PATHOLOGY
Judith Vople, MD, 106 Orlando Blvd.,
Toms River, NJ 08757. UMDNJ 1985.
Board eligible. Group or hospital-
based. Available July 1990.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Woodside
Ave., Trenton, NJ 08618. Rutgers 1980.
Board certified. Part time or full time.
Available.
The History of
Women Physicians
in New Jersey
Copies available
for $6.50 per issue
Send check or money order to:
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
VOL. 87— NUMBER 5 MAY 1990
427
Acupuncture & Electro-Therapeutics
in Clinical Practice
New York State Boards of Medicine & Dentistry
25 -hour accredited seminar & workshop on latest theories
and techniques of manual & electro -acupuncture, TENS &
simple non-invasive diagnostic methods (including
cardio-vascular, neuromuscular, central nervous systems &
"Bi-Digital O-Ring Test"), applicable towards 300-hour
requirement for certification to practice acupuncture, will be
given periodically for licensed clinicians (with or without
prior training) on 3-day weekends (Fri-Sun) of March
23-25, May 11-13, June 15-17, July 13-15, Sept. 21-23,
and Dec. 14-16, 1990, at Milford Plaza Hotel, 45th St. &
8th Ave., or 1 10 Fulton St. (12th fl.). New York City.
The 6th Annual International Symposium on
Acupuncture & Electro-Therapeutics will be held at
Columbia University, School of International Affairs, 420
W. 118th St., N.Y. City, during October 25-28, 1990.
These meetings are co-sponsored by the International
College of Acupuncture & Electro-Therapeutics & its official
journal. Acupuncture & Electro-Therapeutics Research. The
International Journal (.published by Pergamon Press &
indexed in 15 major indexing periodicals, including Index
Medicus), Heart Disease Res. Foundn, N Y Pain Center of
Long Island College Hospital (a teaching hospital of
SUNY-Health Science Center at Brooklyn); Electrical
Engineering Dept., Manhattan College; Nordic Medical
Acupuncture Society (Scandinavia); Schmerz Therapeutische
Kolloquium (West Germany); Japan Bi-Digital O-Ring Test
Assn; etc. The meetings are also eligible for AMA CME Cat.
I credit (about 40 credit-hours for the Symposium).
For information on meetings or submission or
presentation of papers, contact Symposium Chairman Y.
Omura, M.D., Sc.D., 800 Riverside Drive (8-1) New York,
NY 10032 Tel: (212) 781-6262 (10am to 10pm 7 days a
week) or (212) 928-0658, Dr. Shinnick (212) 727-9674, or
Bro. Michael Losco (212) 920-0162.
MARY ANN HAMBURGER
Mary Ann Hamburger is a Medical Management
Consultant and an EXPERT in CPT Codes
She can put your practice on the right
REIMBURSEMENT TRACK!
Sorting out third-party payment codes accurately and fairly is essential to
today's successful office practice • Mary Ann Hamburger Associates has
researched the CPT Codes and knows them thoroughly. Whatever your
specialty, she can help you obtain the best compensation for your services
• Setting a Fee Schedule appropriate to your specialty, your geographic
area and changing market conditions is the first step in a better billing
system • Mary Ann Hamburger Associates has the know-how and the
sensitivity to get this critical office function working at its best • State-of-
the-art office administration frees the physician to practice fine medicine
and keep up on the latest developments • Mary Ann Hamburger Associates
makes sure the business side of your practice gets the honest, personalized
attention it needs • For a whole new approach to office practice
CONTACT MARY ANN HAMBURGER
74 HUDSON AVENUE 201
MAPLEWOOD NEW JERSEY 07040
763-7394
Pointing the
way to more
CME credit.
Earn more CME credit
with Postgraduate
Medicine’s new and
improved CME Program
sponsored by the
Interstate Postgraduate
Medical Association.
More CME credits for
less money ($10.00).
Practical questions
covering the most im-
portant points from
each article— not just
one symposium article.
Now, more than ever,
you’ll want to read
every issue of
Postgraduate Medicine
from cover to cover!
4530 W 77th Street
Minneapolis, MN 55435
(612)835-3222
428
NEW JERSEY MEDICINE
ALLERGY
June
21- In Vitro Allergy Seminar
24 The Registry Resort, Naples,
Florida
(Holy Name Hospital)
ANESTHESIOLOGY
June
13 Monthly Conference
20 7-7:30 A. M. — Newcomb Medical
Center, Vineland
(Newcomb Medical Center)
28 Grand Rounds
7-8 A.M. — Newcomb Medical
Center, Vineland
(Newcomb Medical Center)
CARDIOLOGY
June
6 17th Annual Pacemaker
Meeting
8:30 A.M. -3:30 P.M. — Overlook
Hospital, Summit
(Overlook Hospital and Newark
Beth Israel Medical Center)
DERMATOLOGY
June
20 Summer Skin Problems
1:30-2:30 P.M. — HMO,
New Brunswick
(Rutgers Community Health
Plan)
28 Common Tumors of the Skin
12 Noon-1 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
INFECTIOUS DISEASE
June
1 Clinical Management of HIV
8 Infection
8:30-9:30 A.M. — Chilton Memorial
Hospital, Pompton Plains
(AMNJ and NJDOH)
6 Clinical Management of HIV
Infection
10:30-11:30 A.M. — Christ
Hospital, Jersey City
(AMNJ and NJDOH)
6 Psychiatric Aspects of AIDS
2-3 P.M. — John E. Runnells
Hospital of Union County,
Berkeley Heights
(AMNJ and NJDOH)
7 Clinical Management of HIV
Infection
10-11 A.M. — Meadowview
Hospital, Seacaucus
(Meadowview Hospital)
8 Counseling and Testing for HIV
Infection
8:30-9:30 A.M. — Chilton Memorial
Hospital, Pompton Plains
(AMNJ and NJDOH)
9 AIDS and the Obstetrician/
Gynecologist
10:30-11:15 A.M. — Trump Plaza
Hotel Casino, Atlantic City
(AMNJ and NJDOH)
13 Counseling and Testing for HIV
Infection
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ and NJDOH)
13 AIDS Update
11 A.M. -12 Noon— West Hudson
Hospital, Kearny
(West Hudson Hospital)
22 Clinical Management of HIV
Infection
12 Noon-1 P.M. — Medical Center
of Ocean County, Point Pleasant
(AMNJ and NJDOH)
27 Clinical Management of HIV
Infection
9-10 A.M. —Elizabeth General
Hospital Center, Elizabeth
(AMNJ and NJDOH)
MEDICINE
June
1 Prevention of Lower Extremity
Amputations
9-10 A.M. — St. Francis Medical
Center, Trenton
(AMNJ and NJDOH)
1 Continuing Medical
8 Education Program
15 12 Noon-1 P.M. — South Jersey
22 Hospital System, Bridgeton
29 ( South Jersey Hospital System)
1 Diabetic Retinopathy
9-10 A.M. — St. Francis Medical
Center, Trenton
(AMNJ and NJDOH)
4- 11th Annual Comprehensive
22 Course in Occupational Health
8:30 A.M. -5 P.M. — Robert Wood
Johnson Medical School,
Piscataway
(UMDNJ)
5- Annual Meeting
6 Trump Plaza Hotel and Casino,
Atlantic City
(NJ Gastroenterological Society
and NJ Society for
Gastroenterological Endoscopy)
5 Fourth Annual Internal
12 Medicine Board Review
19 5:30-7:30 P.M. — Cooper Hospital,
26 Camden
( Cooper Hospital/UMDNJ)
5 Epidemiology of Salmonella in
Eggs
12:15-1:30 P.M.— John Fitch
Plaza, Trenton
(NJDOH)
6 Lyme Disease
1:30-2:30 A.M. —HMO,
New Brunswick
(Rutgers Community Health
Plan)
6 Adrenal Disease
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
6 Medical Lecture Series
13 10:30-11:30 A.M.— Christ
Hospital, Jersey City
( Christ Hospital)
6 New Approaches to the
Treatment of Hypertension
10:30 A.M. -12 Noon — General
Hospital Center, Passaic
( General Hospital Center)
6 Review Course in Internal
13 Medicine
20 11 A.M. -1P.M. — Bayonne
27 Hospital, Bayonne
(Bayonne Hospital)
6 Annual Meeting
3-9 P.M. — The Manor,
West Orange
(NJ Gastroenterological Society/
NJ Society for Gastrointestinal
Endoscopy)
VOL. 87— NUMBER 5 MAY 1990
429
7 Erythropoietin
11 A.M. — St. Joseph’s Hospital
and Medical Center, Paterson
(St. Joseph ’s Hospital and
Medical Center)
7- Medical Literature Searching
8 8:30 A. M. -1 P.M.— Health
Sciences Libraries, UMDNJ,
Newark
(UMDNJ)
9 Diabetes and Pregnancy
10:30-11:15 A.M. — Trump Plaza
Hotel Casino, Atlantic City
(AMNJ and NJDOH)
11 Lyme Disease
11:30 A.M.-l P.M. — East Orange
General Hospital, East Orange
(AMNJ)
12 Renal Biopsy Conference
12:30-2 P.M. — Barnert Memorial
Hospital Center, Paterson
(Barnert Memorial Hospital
Center)
12 Malpractice Prevention
8:30 A.M. — Elizabeth General
Medical Center, Elizabeth
(Elizabeth General Medical
Center)
13 Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
13 Critical Health Care Issues in
the Workplace: AIDS and
Substance Abuse
8 A.M. -5 P.M. — Sheraton Fairfield
Hotel
(Oxford Managed Health Care,
Inc.)
13 Mild to Moderate Hypertension
1-1:30 P.M. — Deborah Heart and
Lung Center, Browns Mills
(Deborah Heart and Lung Center)
13 Parkinson’s Disease
8:30 A.M. -5 P.M. — Robert Wood
Johnson Medical School,
Piscataway
(UMDNJ)
13 Parkinsonism
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
13 Diabetic Retinopathy
9-10 A.M. — Elizabeth General
Medical Center, Elizabeth
(AMNJ)
13 Diabetic Nephropathy
9-10 A.M. — Somerset Medical
Center, Somerville
(AMNJ)
13 Diabetes and Pregnancy
11:30 A.M. -12:30 P.M.— Hamilton
Hospital, Trenton
(AMNJ and NJDOH)
14 Aspiration Syndrome in the
Mentally Retarded
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
1-2 P.M. — Woodbridge
Developmental Center,
Woodbridge
(AMNJ)
14 Controlling the Tobacco
Epidemic
12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(NJDOH)
14- Sinus Endoscopy
15 7 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
15 Diabetes and Pregnancy
9-10 A.M. — St. Francis Medical
Center, Trenton
(AMNJ and NJDOH)
19 Pursuing Universal Access to
Health Care
12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(NJDOH)
20 Medical Aspects of Nutrition —
Anorexia and Weight Loss
2:30-3:30 P.M. —Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
21 Continuing Medical
Education Series
12 Noon-1 P.M. — Somerset
Medical Center, Somerville
(Somerset Medical Center)
21 Diabetes and Pregnancy
8:30-9:30 A.M. — Dover General
Hospital, Dover
(AMNJ and NJDOH)
21 Newer Methodology in
Detection and Management of
Pulmonary Embolism
5-7 P.M. — Somerset Medical
Center, Somerville
(Somerset Medical Center)
26 Movement Analyses in
Nonverbal Therapies
8:30-10 A.M. — Elizabeth General
Medical Center, Elizabeth
(Elizabeth General Medical
Center)
27 Diabetes and Pregnancy
1:30-2:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(AMNJ and NJDOH)
29 Developmental Disabilities
Journal Club for Physicians and
Dentists
11:30 A.M. -12:30 P.M.—
Hunterdon Developmental
Center, Clinton
(Hunterdon Developmental
Center)
July
3 Grand Rounds
10 8:30-10 A.M. — Elizabeth General
17 Medical Center, Elizabeth
430
NEW JERSEY MEDICINE
24 (Elizabeth General Medical
31 Center)
OBSTETRICS/GYNECOLOGY
June
5 Medical Grand Rounds
12 9:30 A.M.-3 P.M. — Holy Name
19 Hospital, Teaneck
(Holy Name Hospital)
8- 42nd Annual Meeting
9 Trump Plaza Hotel Casino,
Atlantic City
(New Jersey Obstetrical and
Gynecological Society)
9 AIDS and the Obstetrician/
Gynecologist
10:30-11:15 A.M. — Trump Plaza
Hotel Casino, Atlantic City
(New Jersey Obstetrical and
Gynecological Society)
9 Diabetes and Pregnancy
10:30-11:15 A.M. — Trump Plaza
Hotel Casino, Atlantic City
(AMNJ and NJDOH)
13 Diabetes and Pregnancy
11:30 A.M. -12:30 P.M. — Hamilton
Hospital, Trenton
(AMNJ and NJDOH)
16- Risk Management
17 in Obstetrics/Gynecology
8 A.M. -5 P.M. — The Diplomate
Hotel, Atlantic City
(UMDNJ)
21 Diabetes and Pregnancy
8:30-9:30 A.M. — Dover General
Hospital, Dover
(AMNJ and NJDOH)
21 Neonatal Problems
7:30-8:30 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
27 Diabetes and Pregnancy
1:30-2:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(AMNJ and NJDOH)
OCCUPATIONAL MEDICINE
June
6 Occupational Asthma in
New Jersey
10:30-11:30 A.M. — Christ
Hospital, Jersey City
(AMNJ)
ONCOLOGY
June
8 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
13 Tumor Board Conference
12 Noon-1 P.M. — Memorial
Hospital of Salem County, Salem
(Memorial Hospital of Salem
County)
13 Tumor Board/Case
Presentation
9-10 A.M. — Irvington General
Hospital, Irvington
(Irvington General Hospital)
28 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(Newcomb Medical Center)
July
13 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
OPHTHALMOLOGY
June
7- Immunologic Disorders of the
8 Visual System
8 A.M. -5 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
PEDIATRICS
June
27 Office Practicum: 1990
9:15 A.M. -3:30 P.M. — Ramada
Inn, Clark
( Children ’s Hospital
of New Jersey)
29 Management of Pain in
Pediatrics
12 Noon-l:30 P.M. — Mercer
Medical Center, Trenton
(Mercer Medical Center)
PSYCHIATRY
June
5 Psychiatry Grand Rounds
12 8:30-10 A.M. — Elizabeth General
19 Medical Center, Elizabeth
26 (Elizabeth General Medical
Center)
6 Psychiatric Aspect s of AIDS
2-3 P.M. — John E. Runnells
Hospital of Union County,
Berkeley Heights
(AMNJ)
21 Case Seminars To Improve
Psychotherapeutic Technique
8-10 P.M. — 2 West Northfield
Road, Livingston
(Advanced Psychiatric Study
Group)
7 Brain, Biology, and Behavior
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
14 Maintenance ECT: When
and How?
12 Noon-1 P.M. — All Day, Carrier
Foundation, Belle Mead
( Carrier Foundation)
21 Effects of Brain Injury on
Behavior and Emotions
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
27 Obsessive Compulsive Disorder
and its Relationship to
Depression
12 Noon-1 P.M. — Trenton
Psychiatric Hospital, Trenton
(Trenton Psychiatric Hospital)
27 Grand Rounds
2:30-4 P.M. — Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital)
July
3 Psychiatry Grand Rounds
10 8:30-10 A.M. — Elizabeth General
17 Medical Center, Elizabeth
24 (Elizabeth General Medical
31 Center)
SURGERY AND ITS SPECIALTIES
June
5 Weekly Vascular Case
12 Conference
19 7:30-8:30 A.M. —Robert Wood
26 Johnson Medical School, MEB,
108B, New Brunswick
(UMDNJ)
6 Vascular Grand Rounds
13 4:30-5:30 P.M. — New Jersey
20 Medical School, B610,
27 Newark
(UMDNJ)
8 Diagnosis and Surgical
Management of Esophageal
Reflux and Hiatus Hernia
1-2 P.M. — North Princeton
Developmental Center, Princeton
(AMNJ)
20 High-Risk Surgery
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
21 Surgical Grand Rounds
Program
5-6 P.M. — Shore Memorial
Hospital, Somers Point
(Shore Memorial Hospital)
25 Surgical Management of Benign
and Malignant Diseases
12 Noon-1 P.M. — Hospital Center
at Orange, Orange
(AMNJ)
UROLOGY
June
1 Urology Grand Rounds
8 3-5 P.M. — New Jersey Medical
15 School, MSB, C600, Newark
22 (UMDNJ)
VOL. 87— NUMBER 5 MAY 1990
431
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432
NEW JERSEY MEDICINE
Frank J. Albano. At the age of
80, Frank Albano, MD, a member
of our Essex County component,
died on February 27, 1990. Born on
July 19, 1909, in Newark, Dr.
Albano received his medical degree
from the Faculty of Medicine Uni-
versity of Rome, Italy, in 1936 and
his New Jersey license in 1938. A
lifelong resident of Newark, Dr.
Albano had his private surgical
practice there for 50 years. In ad-
dition, Dr. Albano was a staff
physician at Columbus Hospital,
Newark, and at Clara Maass
Medical Center, Belleville. Dr.
Albano served in the United States
Army during World War II and was
a retired National Guard colonel.
Dr. Albano also was a member of
the American College of Emer-
gency Physicians and of the Ameri-
can Association of Military Sur-
geons.
Robert P, Boyd. Word has been
received of the death of Robert
Peterson Boyd, MD, on February
5, 1990, of heart problems. A mem-
ber of our Union County compo-
nent, Dr. Boyd was a general prac-
titioner, affiliated with Muhlen-
berg Regional Medical Center,
Plainfield. Born in 1904 in Chi-
cago, Illinois, Dr. Boyd was
awarded his medical degree from
Temple University Medical
School, Pennsylvania, in 1936. He
completed an internship and resi-
dency at Muhlenberg Regional
Medical Center, Plainfield, and
from 1943 to 1947 served in the
medical corps as a major. Dr. Boyd
was a member of the American
Medical Association.
Anthony Fernicola. At the age
of 72, retired urologist Anthony
Ralph Fernicola, MD, died on
January 29, 1990. Dr. Fernicola
had practiced in Newark since
1950, retiring in 1987. During his
tenure, he was president of the
medical staff of St. James Hospital
and was an attending urologist at
St. James and Columbus Hospi-
tals, both in Newark, and at Clara
Maass Medical Center, Belleville.
Dr. Fernicola was the pioneer phy-
sician for the operative procedure,
retrospective prostatectomy, and
established urological entities re-
lated to infection, obstruction, and
tumor of the genitourinary system.
Dr. Fernicola was a member of our
Essex County component and of
the American Medical Associa-
tion; he was a diplomate of the
American Board of Urology; and a
fellow of the American College of
Surgeons and of the Academy of
Medicine of New Jersey. He was a
published writer of numerous
articles and a member of the
American Medical Writers As-
sociation, and was a winner of the
New York Urological Society Prize
Essay. Born in 1917 in Newark, Dr.
Fernicola earned his medical
degree from Georgetown Univer-
sity Medical School, Washington,
DC, in 1945, and received his New
Jersey medical license the follow-
ing year. He served a residency and
internship in urology at Newark
City Hospital.
Cleo J.L. Froix. A member of
our Camden County component,
Cleo Joseph L. Froix, MD, died on
February 6, 1990. Born in 1919 in
Trinidad, West Indies, Dr. Froix
received his medical degree from
Howard University College of
Medicine, Washington, DC, in
1953. He completed an internship
at Kings County Medical Center,
New York, and a surgical residency
at Harlem Hospital, New York,
and at Godfrey Hospital, Paris,
France. Licensed in Maryland,
New York, and Hawaii, Dr. Froix
relocated to New Jersey in 1987
after receiving his medical license.
Dr. Froix was a fellow of the
IN MEMORIAM
Please send all information for
member obituaries to the
following address:
Membership Department
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
VOL. 87— NUMBER 5 MAY 1990
433
American College of Surgeons and
of the American Society of Ab-
dominal Surgeons; a diplomate of
the Pan American Medical As-
sociation; and a member of the
American Medical Association.
Vincent J. McAuliffe. Teaneck
pediatrician for 40 years, Vincent
Joseph McAuliffe, MD, died on
February 24, 1990, at the age of 74.
Born in Jersey City, Dr. McAuliffe
earned his medical degree from
Georgetown University School of
Medicine, Washington, DC, in
1942; he obtained his license to
practice in New Jersey the follow-
ing year. After completing his
pediatric residency at Children’s
Hospital in Washington, DC, Dr.
McAuliffe moved to Teaneck in
1948. During his lengthy career,
Dr. McAuliffe served as chief of
pediatrics and as president of the
medical staff at Holy Name Hospi-
tal, Teaneck. Dr. McAuliffe was a
member of our Bergen County
component and of the American
Medical Association; he was a fel-
low of the American Academy of
Pediatrics; and he was a diplomate
of the American Board of Pedi-
atrics. During World War II, Dr.
McAuliffe served as a United
States Army captain.
Ramiro Mireles. At the age of
61, Ramiro Mireles, MD, a mem-
ber of our Union County compo-
nent, died on February 2, 1990.
Born in Mexico, Dr. Mireles
earned his medical degree from
Universidad de Nuevo Leon,
Monterre, Mexico, in 1951. He
then moved to Hillside, and prac-
ticed in Elizabeth as a general sur-
geon and gynecologist, until his
death. During his career, Dr.
Mireles was affiliated with St.
Elizabeth Hospital, Alexian
Brothers Hospital, and Elizabeth
General Medical Center, all in
Elizabeth. Dr. Mireles was a mem-
ber of the American Medical As-
sociation and of the Pan American
College of Surgeons, and a fellow of
the American College of Surgeons.
Louis Rosenberg. Word has
been received of the death of a re-
tired member of our Atlantic
County component, Louis Rosen-
berg, MD. Born in 1903 in Atlantic
City, Dr. Rosenberg earned his
medical degree at Jefferson Medi-
cal College, Pennsylvania, in 1926;
the following year he was awarded
his New Jersey medical license.
For over 50 years, Dr. Rosenberg
practiced in Atlantic City, with a
specialty in circulatory diseases.
He was affiliated with Atlantic
City Medical Center and served as
president of the Atlantic County
Medical Society; he was a member
of the American Medical Associa-
tion and a fellow of the American
College of Angiology. Dr. Rosen-
berg retired from the practice of
medicine in 1977. From July 1942
to 1946, Dr. Rosenberg served in
the U.S. Medical Corps as a major.
Francis U. Seiler. Francis Ulric
Seiler, MD, of Robbinsville and a
member of our Mercer County
component, died on February 22,
1990, at the age of 67. Born in 1922
in Trenton, Dr. Seiler earned his
medical degree from Hahnemann
Medical School, Philadelphia, in
1947. Dr. Seiler served an in-
ternship at St. Francis Medical
Center, Trenton, from 1947 to
1948, and completed a residency in
obstetrics/gynecology at Tampa
Municipal Hospital, Florida, in
1949; at Aultman Hospital, Can-
ton, Ohio, in 1950; and at Col-
umbia Hospital, Washington, DC,
in 1953. In July 1953, Dr. Seiler
opened a private practice in ob-
stetrics/gynecology, and was af-
filiated with St. Francis Medical
Center. Dr. Seiler was a fellow of
the American College of Obstet-
rics/Gynecology and of the Ameri-
can College of Surgeons. Dr. Seiler
retired from active practice in
1983.
Arthur C. Tutela. At the age of
80, Arthur Constantine Tutela,
MD, a member of our Essex Coun-
ty component, died on January i0,
1990. Born in Newark, Dr. Tutela
was awarded his medical degree
from Loyola University Medical
School, Illinois, in 1938. After
serving an internship at Saint
Michael’s Medical Center, New-
ark, Dr. Tutela received his license
to practice in New Jersey in 1939.
Dr. Tutela was a physician in
Short Hills and Newark for 50
years; he was affiliated with Saint
Barnabas Medical Center, Liv-
ingston, and Saint Michael’s
Medical Center and Columbus
Hospital, both in Newark. A gen-
eral physician, Dr. Tutela was a
member of the American Medical
Association and a fellow of the
Academy of Medicine of New Jer-
sey. Dr. Tutela served as a captain
in the Army during World War II
and received a Purple Heart and
the Bronze Star for action in the
Battle of the Bulge.
William Weissberg. Elizabeth
physician William Weissberg, MD,
died on January 13, 1990, at the
age of 75. Born in Newark, Dr.
Weissberg earned his medical
degree at Cincinnati Medical Col-
lege, Ohio, in 1939. He served an
internship at Elizabeth General
Hospital and a residency at Bronx
Hospital, New York. Dr. Weiss-
berg, an internist, was founder and
partner of the Elizabeth Medical
Group for 40 years. During his
lengthy career, Dr. Weissberg was
affiliated with St. Elizabeth Hos-
pital, Elizabeth General Medical
Center, and Alexian Brothers Hos-
pital, all in Elizabeth. Dr. Weiss-
berg was a diplomate of the Ameri-
can Board of Internal Medicine, a
fellow of the American College of
Physicians, and a member of our
Union County component and of
the American Medical Association.
During his tenure at Elizabeth
General Medical Center, Dr.
Weissberg was president of the
medical board and of the clinical
society. During World War II, Dr.
Weissberg served as a major in the
medical corps of the Army in the
Pacific Theatre.
434
NEW JERSEY MEDICINE
"CLEAR AND CONVINCING" EVIDENCE BILL
RELEASED FROM COMMITTEE
The Senate Committee on Institutions, Health and Welfare
released S-2608 from Committee on May 17, 1990. The bill
elevates the burden of proof to "clear and convincing" in
medical licensing actions. That standard was recommended to
the Legislature by Herbert S. Stern, Esq., special counsel
to MSNJ , as being both prudent and fair. Senate approval is
expected before the summer recess.
MALPRACTICE SURCHARGE SUIT
MSNJ ' s suit against the State Department of Insurance will be
argued before the Appellate Division in September if the
Court maintains its schedule. MSNJ and MIIENJ have filed
briefs and the State has not done so; the Court granted an
extension due to illness and personal scheduling difficulties
of the deputy attorney general representing the DOI.
REQUEST PIP ARBITRATION
IF THE CARRIER DOES NOT PAY
Many physician have had their fees reduced or denied by
automobile carriers. If you are displeased by such actions,
you should notify the carrier in writing that you are
requesting arbitration under the PIP statute and use an
arbitrator from the American Arbitration Association list. A
copy of your arbitration request should be sent to Vincent A.
Maressa at the Medical Society of New Jersey, Two Princess
Road, Lawrenceville, NJ 08648.
-
MSNJ
NEWSLETTER
RADIOLOGY With this issue of NEW JERSEY MEDICINE, we welcome bimonthly
ROUNDS/REVIEW columns entitled, “Radiology Rounds” and “Radiology Review.” The
format will include a radiograph and clinical issue, as well as a brief
discussion and diagnosis; selected references will be noted. Contributions
for this column are welcome, and guest editors Drs. Jacoby and Zeiger
invite participation. We know these two columns will be a valuable
addition to our state medical journal.
The Department of Health has issued proposed changes to the 1990
Medicare Cost Shift Methodology for the July 1990 calculations. The
proposed methodology covers: Part B physician costs, updates of Medix
UB data, and treatment of PPS excluded units. Blue Cross will use 1988
Medicare cost report data to remove Part B physician costs from the
Chapter 83 portion of the calculations and exclude these costs from the
Medicare payment portion. Data from 1989 may not be complete in time
for inclusion in the calculation, so the Department proposes to use the
1988 UB data used in the January calculations. This data will be up-
dated for additional cases, corrections to DRG assignments, and sepa-
ration of same-day medical cases. The Department anticipates contact-
ing hospitals that have PPS excluded units to determine whether these
units are included in the hospitals’ 1990 Chapter 83 rates. If they are
included in their rates, the Department intends to include Medicare
payments for these units in the cost shift calculation.
BLUE CROSS The 350,000 individual Blue Cross and Blue Shield policyholders will
PREMIUM REVISIONS soon receive revised rates after the state Insurance Department ordered
the insurer to set rates without regard to demographics. The order was
issued in response to an Appellate Division of Superior Court ruling that
found it illegal for Blue Cross and Blue Shield, as a tax-exempt carrier,
to set rates based on age, gender, or residence. The revised rate schedule
does not apply to the 250,000 senior citizens with supplemental Medicare
policies, or to student health policies. Blue Cross and Blue Shield of-
ficials fear that, as a result of the ruling, it will continue to lose low-
risk customers to commercial insurance carriers that are able to reject
high-risk applicants, and provide low-risk applicants with better rates.
The New Jersey Hospital Association has reported that the shortage of
nurses in New Jersey has improved in 44 percent of hospitals that
responded to a survey. The Association also reported that the statewide
average nursing position vacancy rate was 17 percent in 1989, the same
vacancy rate reported for 1987. The 23 percent of hospitals that reported
increases in the vacancy rate, for the most part, were inner-city hospitals,
or hospitals bordering neighboring states.
PRO REPORT The Institute of Medicine (IOM) released their report on their study of
CRITICISMS PROs, mandated by the 1986 Consolidated Omnibus Budget Reconcili-
ation Act. The report indicates that PROs spend too much time focusing
on cost and utilization rather than the quality of patient care. The report
recommends changing the existing PRO program into a “Medicare Pro-
NURSING
SHORTAGE
MEDICARE
COST SHIFT
VOL. 87— NUMBER 6 JUNE 1990
449
MSNJ NEWSLETTER
gram To Assure Quality.” This program would gather data on obtaining
the most appropriate types of care for patients and provide patients with
more information. Gail R. Wilensky, HCFA administrator, said HCFA
does not agree with IOMs suggestions for a new advisory type program.
Wilensky commented that HCFA currently is gathering data to help the
PRO program “change from the review of individual case records to the
monitoring of practice patterns and outcomes of care.”
ELDERLY A report released by the House Select Committee on Aging reports that
HEALTH COSTS the elderly’s annual out-of-pocket costs for health care have increased
from $700 per capita in 1977 to $2,400 per capita in 1988. Committee
Chairman Edward R. Roybal (D-CA) estimates that unless the govern-
ment intervenes, out-of-pocket health care costs soon will consume 20
percent of the elderly’s limited income. This Committee is continuing
its investigation of insurance sold to the elderly to cover health care costs
and the related sales methods employed and commissions generated.
NATIONAL A study performed by the National Center for Policy Analysis, Dallas,
HEALTH PLAN found that if the U.S. implements a national health insurance plan,
manufacturers would see their health care costs increase by 50 percent;
such a plan would require, at a minimum, $339 billion in new taxes.
PROSPECTIVE HCFA Administrator Gail Wilensky reaffirmed Health and Human Ser-
CAPSTAL vices (HHS) intent to establish a prospectively based hospital capital
PAYMENTS Payment system. She urged hospital industry participation in the dis-
cussion process so that comments could be considered in the proposed
capital rule expected to be published late this summer. Federal law
requires capital payments to be incorporated into PPS payments by
October 1, 1991. Earlier efforts to establish prospective capital rates in
1987 and 1988 were stalled by Congress. Indications are that the 1987
capital payment plan would be the basis for current proposal delibera-
tions. That plan featured varying transition periods for incorporating
fixed and movable capital costs, adjustments for urban and rural classi-
fication, and sole community provider exemptions. Medicare currently
reimburses acute hospital inpatient capital expenses at 85 percent of
reasonable costs. The Administration’s 1991 budget proposal provides
for further reduction to 75 percent for urban hospitals and 85 percent
for rural hospitals.
AMA REFORM The AMA has presented a broad health care reform proposal rec-
PLAN ommending substantial changes in Medicare, Medicaid, and employer-
purchased health insurance. The plan is designed to improve access to
high-quality, affordable health care services. The reform proposal rec-
ommends building on the strengths of the current health care system,
including: changing the current professional liability system; establish-
ing provider-developed practice parameters; strengthening Medicare
trust fund balances by prefunding; establishing state risk pools to
provide group health coverage for the uninsured and requiring national
standard health benefits as opposed to more costly individual state-
mandated benefits.
NURSING HOME HCFA has proposed a rule that requires nursing homes to screen all
SCREENINGS residents for retardation and mental illness. Homes that do not comply
risk exclusion from the Medicare and Medicaid programs.
ANTITRUST The AMA’s Physician Negotiation Advisory Office is ready to help you
VIOLATIONS bargain with HMOs, insurance companies, and other third-party payers.
This AMA service can boost your negotiating power and answer your
questions about antitrust laws. The AMA has a telephone “hotline” to
field your questions on the subject. Just call 312/645-5601. A referral list
450
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
of attorneys experienced in antitrust also is available. As an AMA mem-
ber, you can receive a free booklet called “Collective Negotiation and
Antitrust,” by writing to: Physician Negotiation Advisory Office, AMA,
535 North Dearborn, Chicago 60610. Attention: Michael He, JD, or call
312/645-5601.
CDC
GUIDELINES
Potential exposure to HIV and other blood-borne pathogens is a risk
every physician faces. After reviewing all the proposed standards for
protecting health workers from exposure, the AMA concluded that the
Centers for Disease Control’s guidelines present the best methods of
preventing occupational transmission. The AMA testified to that effect
before the Occupational Safety and Health Administration (OSHA). In
addition, the AMA urged OSHA to train enough field staff to conduct
infection control inspections without disrupting the delivery of quality
care.
GROUP
PRACTICE
If you practice in a large group or are employed by an HMO, you should
know that the AMA has created a Department of Group Practice Physi-
cians. This department will serve as your direct link to the AMA when
you need representation on payment reform, regulatory issues, and refer-
ral problems. A Committee on Group Practice Physicians has been
formed, made up of members from leading clinics throughout the coun-
try. The Committee will meet to advise the AMA on policy and to
develop programs that meet your needs.
APPLICATIONS
FOR CDS
There is a delay in sending out renewal applications for CDS regis-
trations that expired on March 31, 1990. Likewise, there may be a delay
in subsequent renewal periods until the transition from a manual system
to an automated one is in place. Those practitioners whose registrations
expired on December 31, 1989, or prior to that date should be able to
provide copies of their renewal applications to indicate that they have
fulfilled their obligations in returning the renewal form. The copy of the
renewal application should have the blocks on the lower right-hand side
completed with the check number, date of check, and the amount of
$20.
SCREENING
PARAMETERS
The Health Care Financing Administration (HCFA) has become aware
of individuals offering physicians the opportunity to purchase the
HCFA-mandated medical review screening parameters. This infor-
mation has not been provided by HCFA or an agent of HCFA. This
information may not be accurate and these parameters are subject to
ongoing revision. Please remember that information in publications is-
sued from sources other than Pennsylvania Blue Shield or HCFA is not
considered official notice from your Medicare Carrier. Pennsylvania Blue
Shield informs physicians and suppliers of Medicare Program provisions
via Medicare Report, Medicare special bulletins, special mailings, and
stuffers inserted with their Explanation of Medicare Benefits. It is im-
portant that physicians recognize these forms of Pennsylvania Blue
Shield communications as their official notice of Medicare Program
provisions, policies, and billing procedures.
MEDI-FILE
CARDS
The Medical Society of New Jersey, in cooperation with the Medical
Society of New Jersey Auxiliary, is making a file card available for
physician distribution to their patients. This card is a record of all the
medications the patient currently is using. It also lists any known al-
lergies and other pertinent medical information. The Auxiliary has been
distributing these as a doctor/patient service, and copies may be ob-
tained from the Public Relations Department, MSNJ, 609/896-1766.
FINI
“No man was ever wise by chance.” □
VOL. 87— NUMBER 6 JUNE 1990
451
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LEVOXINE® ( Levothyroxine Sodium Tablets, USP) For oral administr
The following is a brief summary. Before prescribing please consult package ins<
INDICATIONS AND USAGE:
LEVOXINE (L-thyroxine) tablets are indicated as replacement or supplemental the
for diminished or absent thyroid function, resulting from functional deficiency, pri
atrophy, from partial or complete absence of the gland or from the effects of sur
radiation or antithyroid agents. Therapy must be maintained continuously to contrc
symptoms of hypothyroidism.
CONTRAINDICATIONS:
L-thyroxine therapy is contraindicated in thyrotoxicosis, acute myocardial infari
and uncorrected adrenal insufficiency.
WARNINGS:
Drugs with thyroid hormone activity, alone or together with other therapeutic agents hr
been used for the treatment of obesity. In euthyroid patients doses within the range of di
hormonal requirements are ineffective for weight reduction. Larger doses may prodi
serious or even life-threatening manifestations of toxicity, particularly when given in
sociation with sympathomimetic amines such as those used for anorectic effects
PRECAUTIONS:
Caution must be exercised in the administration of this drug to patients with cardir
cular disease. Development of chest pains or other aggravation of the cardiovascula
ease requires a reduction of dosage
Patients on thyroid preparations and parents of children on thyroid therapy shou
informed that replacement therapy is to be taken essentially for life They shouli
mediately report during the course of therapy any signs or symptoms of thyroid horn
toxicity, eg, chest pains increased pulse rate, palpitations excessive sweating,
intolerance, nervousness or any other unusual event In case of concomitant diat
mellitus the daily dosage of antidiabetic medication may need readjustment In ca
concomitant oral anticoagulant therapy, the prothrombin time should be measurec
quently to determine if the dosage of oral anticoagulants is to be readjusted.
Partial loss of hair may be experienced by children in the first few months of thy
therapy, but this is usually a transient phenomenon and later recovery is usually
rule
Drug Interactions — In patients with diabetes mellitus addition of thyroid horn
therapy may cause an increase in the required dosage of insulin or oral hypoglyo
agents
Patients stabilized on oral anticoagulants who are found to require thyroid repl
ment therapy should be watched very closely when therapy is started.
Cholestyramine binds both T4 and T3 in the intestine thus impairing absorptic
these thyroid hormones Four to five hours should elapse between administrate
cholestyramine and thyroid hormones
Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients withi
functioning thyroid gland who are on thyroid replacement therapy may need to incri
their thyroid dose if estrogens or estrogen-containing oral contraceptives are give
Drug/Laboratory Test Interactions — The following drugs or moieties are known to i
fere with laboratory tests performed on patients taking thyroid hormone: androgens
ticosteroids estrogens oral contraceptives containing estrogens iodine-contai
preparations and the numerous preparations containing salicylates
Carcinogenesis, Mutagenesis, And Impairment of Fertility — A reported apparen
sociation between prolonged thyroid therapy and breast cancer has not been confiri
No confirmatory long-term studies in animals have been performed to evaluate
cinogenic potential, mutagenicity, or impairment of fertility in either males or feme
Pregnancy-Category A — The clinical experience to date does not indicate any adv
effect on fetuses when thyroid hormones are administered to pregnant women.
Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human
Thyroid is not associated with serious adverse reactions and does not have a kr
tumorigenic potential However, caution should be exercised when thyroid is adrr
tered to a nursing woman.
Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Rot
determinations of serum (T4) and/or TSH is strongly advised in neonates in view o
deleterious effects of thyroid deficiency on growth and development
ADVERSE REACTIONS:
Adverse reactions are due to overdosage and are those of induced hyperthyroidis
OVERDOSAGE — Excessive dosage of thyroid medication may result in sympton
hyperthyroidism, which may not appear for one to three weeks after the dosage regi
is begun The most common signs and symptoms of overdosage are weight loss, pal
tion, nervousness, diarrhea or abdominal cramps, sweating, tachycardia, cardiac a
thmias, angina pectoris, tremors, headache, insomnia, intolerance to heat and fev
symptoms of overdosage appear, discontinue medication for several days and reinst
treatment at a lower dosage level
Complications as a result of the induced hypermetabolic state may include cai
failure and death due to arrhythmia or failure
Dosage should be reduced or therapy temporarily discontinued if signs and sympl
of overdosage appear.
Treatment of acute massive thyroid hormone overdosage is aimed at reducing
trointestinal absorption of the drugs and counteracting central and peripheral eff
mainly those of increased sympathetic activity. Measures to control fever, hypoglycem
fluid loss should be instituted if needed.
DOSAGE FORMS AVAILABLE:
LEVOXINE (L-thyroxine) tablets are supplied as oval color coded, potency mai
tablets in 11 strengths: 12Vi meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - ora
50 meg (0.05 mg) - white, 75 meg (0.075 mg) - purple, 100 meg (0.1 mg) -yellow, 112
(0.112 mg) - rose, 125 meg (0.125 mg) - brown, 150 meg (0.15 mg) - blue, 175
(0.175 mg) -turquoise, 200 meg (0.2 mg) -pink and 300 meg (0.3 mg) - green, in bottl
100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg
500 meg injectable (see injectable package insert).
452
NEW JERSEY MEDICINE
professional
LIABILITY
DATA BANK
GETTING READY
By law, insurance companies, self-insured hospitals, and self-insured
physicians and dentists on whose behalf payments resulting from
malpractice claims or judgments are made must report such information
to the Data Bank. State medical and dental boards, and other organiza-
tions and entities also must report actions affecting clinical privileges
or society membership that are based on a practitioner’s professional
competence or conduct.
Reports must be filed within 30 days of an action, but even here there
are many “what ifs?” For example, at what point does a privilege or
licensure action become final and thus reportable? What should be done
about a practitioner who voluntarily enters a drug or alcohol rehabili-
tation program before an action can proceed?
Refer to the regulations, published in the October 17, 1989, Federal
Register, and do your own legal work on such questions, suggested HHS
spokespersons.
It also is mandatory that every hospital query the Data Bank every two
years regarding physicians, dentists, and other health care practitioners
on their medical staffs or those to whom they have granted clinical
privileges. Similarly, hospitals must query the repository when they are
considering a new applicant for a medical staff appointment or clinical
privileges.
Considering that there are more than a half million practicing physicians
and thousands of dentists, simple arithmetic suggests that a monu-
mental amount of information will be accumulated and divulged.
Now add a new dimension to this process. Insurers were told at the
December 1989 conference, they could ask physicians or dentists apply-
ing for liability coverage to provide copies of their Data Bank reports
with their applications.
“This could generate an additional 500,000 requests for information from
insurers about physicians,” noted Larry Smarr, vice-president for
statistics and research, Pennsylvania Medical Society Liability In-
surance Company.
Daniel D. Cowell, MD, director of the Division of Quality Assurance and
Liability Management, Public Health Service/Department of Health
and Human Services, reported on Data Bank progress. “We are seeking
your support in developing an active partnership to make the Data Bank
It still is uncertain just when the National Practitioner Data Bank will
begin operation. An invitational conference in Chicago for those who
must routinely submit information made one thing very clear: there are
still many unanswered questions and problems yet to be resolved. The
job of obtaining and storing data from literally thousands of insurers,
state licensing boards, professional organizations, hospitals, and physi-
cians is formidable enough. Coping with what could be hundreds of
thousands of inquiries will be a staggering task.
MDL. 87— NUMBER 6 JUNE 1990
455
PROFESSIONAL LIABILITY
work,” Dr. Cowell said. He admitted that there still are many concerns —
access, security, and confidentiality among them — but said, “There is
no way we could dispel them all.” Dr. Cowell said his people were
“adhering to a neutral path.” He urged, “Let it work. It could reflect
very favorably upon the medical profession.”
Dr. Cowell then explained the basic data elements that must be
provided, including a medical malpractice payment report, an adverse
action report, and a licensure, privileges, or membership action. He also
described the information required when an entity requests data.
The biggest problem for those attending was that the actual forms are
not yet ready and still must clear the Office of Management and Budget.
“We do not know what the form looks like. Until we do, we cannot tell
what kind of additional programs we will need,” said James Robb, vice-
president, claims operations, Medical Liability Mutual Insurance Com-
pany of New York.
“Conforming with the Data Bank requirements affects our day-to-day
operations. It impacts very dramatically on how insurers operate. We
are unsure of what rules we play under,” Smarr said.
As the day progressed, it became obvious HHS staffers were in something
of a tough spot, trying to conform with a legislative mandate, while
having to get confirmation for decisions from other government agencies,
such as Office of Management and Budget. Some tempers began to fray
as questions revealed yet-unresolved problems.
State licensing board representatives, for example, were dismayed to
learn that no information will be available on a doctor from another state
applying for licensure in 30 days. “That is a real time frame problem
for us,” said one such representative.
“There are a lot of unanswered questions after today’s meeting,” com-
mented a St. Paul representative. “There needs to be some consensus
before we try to educate our people about the Data Bank.”
Conferees did clarify some points: sealed judgments must be reported;
defense costs need not be included in payment reports; security for the
Data Bank will be very tight; and that only authorized individuals and
entities will be able to extract data.
Somewhat veiled references in new regulations to “expansion” of the
Data Bank also raised red flags to some attendees. Dr. David Masland,
Carlisle, PA, newly appointed to the executive committee for the Data
Bank, said he would argue strongly against the concept of extending the
database.
Throughout the day, speakers stressed that no link between the reporting
of a claim or judgment can be made with the quality of a practitioner’s
services or competence. Nevertheless, these same speakers were firm in
saying that the Data Bank will go forward, regardless of reservations or
reluctance on the part of those the law touches. (Reprinted with per-
mission from Medical Liability Monitor, Winnetka, IL, 60093. January
24, 1990, Volume 15, Number 1)
DELAY DATA BANK
OPENING;
QUESTIONS PERSIST
Startup delays again have postponed the opening of the National Practi-
tioner Data Bank to which all medical malpractice indemnity payments
and other actions affecting licensure or hospital privileges must be re-
ported. For several months, insurers and reporting agenc:es have been
trying to get a handle on the specific requirements they must fulfill and
how to meet them. Many liability insurers still are frustrated, despite
456
NEW JERSEY MEDICINE
several meetings conducted under Data Bank auspices to try to explain
the procedures.
Many insurers say the big stumbling block is the fact that the actual
forms to be used in submitting information with full instructions have
not yet been officially cleared by the Office of Management and Budget.
Word is that after several meetings at which insurers raised specific
questions, several substantive changes in the forms are being considered.
Several information meetings already have been held, including one in
Chicago in December and one for commercial insurers held in New
Orleans in February. At the request of the Physician Insurers Association
of America (PIAA), another meeting was held in late February in
Phoenix. Principal speakers at the Phoenix meeting, attended by nearly
100 PIAA and other representatives, were John E. Hansan, PhD, Data
Bank director, and education manager Mindy C. Reiser, PhD, both of
UNISYS, which has been awarded the contract to operate the repository.
However, no representatives from the Division of Quality Assurance and
Liability Management of the Department of Health and Human Ser-
vices, which has been delegated to oversee Data Bank operations, were
present; still-unaddressed policy issues could not be resolved.
Lawrence E. Smarr, vice-president of statistics and research for Penn-
sylvania Medical Society Liability Insurance Company, who has been
closely following the technical side of Data Bank operations, said that
many of the PIAA company representatives came away still dissatisfied
about unanswered questions, “even such simple ones as whether or not
the Data Bank will accept return receipt requested mail.” Insurers say
they are willing to supply data to the bank, mandated in the Health
Care Quality Improvement Act of 1986, even though it will be time-
consuming and expensive, but are stymied over the nuts-and-bolts
aspects of meeting their obligations.
St. Paul Fire & Marine Insurance Co., the largest commercial pro-
fessional liability carrier, says it has had a task force in place for some
time trying to coordinate various aspects of its involvement in the new
Data Bank. “We have been considering how we can comply with the
statutory requirements, but there still are unanswered questions,” stated
Tim Morse, vice-president of St. Paul’s medical services division.
Divergence of coverage poses special problems for the big carrier, Morse
said. Although there are many first-dollar insureds, there also are a
growing number of customers with significant retentions. In such situ-
ations, reporting requirements become complicated.
“We are educating our own people and our own insureds. We are sending
a brochure to all our insureds explaining the Data Bank, our obligations
to it, and assuring them that, we are going to do what we can to protect
the confidentiality and integrity of the claims files,” Morse said.
Coordinating with the 35 claims service centers and other offices who
will be responsible for making the appropriate filings to both the Data
Bank and the appropriate licensing agencies will take time and effort,
“and that translates into dollars,” Morse noted. He said the company
will make itself available to health care providers when data submitted
is entered and then sent to the providers to check accuracy.
Morse said the company had no plans to ask potential insureds to
provide copies of any Data Bank entries about them. (Reprinted with
permission from Medical Liability Monitor, Winnetka, IL 60093. March
30, 1990, Volume 15, Number 3)
VOL. 87— NUMBER 6 JUNE 1990
457
I
TOWARD
2000 VI
SYMPOSIUM
October
12th
and 13th.
The sixth annual
Toward 2000
Symposium is an
opportunity to
assess progress
toward the goal of
reducing cancer mortality in the United
States. The symposium will be held at Fox
Chase Cancer Center on October 12th and
13th. National experts will conduct seminars,
workshops and informal dinner discussions
focusing on common
solid malignancies
including lung, colon,
and breast. Faculty
will also discuss
advances in
autologous bone marrow transplantation and
the role of immunotherapy.
For more information and hotel
accommodations, please contact Kathy Smith
or Louise Blasick at (215) 728-2715.
As an organization accredited by the Accreditation Council for Continuing Medical
Education, Temple University School of Medicine certifies that this program meets the criteria
for 12 credit hours of Category I, provided it is completed as designed.
With support from Bristol-Myers Oncology Division.
FOX CHASE
CANCER CENTER
DISCOVERY & HOPE.
7701 Burholme Avenue, Philadelphia, PA 19111
458
NEW JERSEY MEDICINE
EDITOR’S
DESK
TOO MANY COOKS Do physicians follow a medical career merely to insure a comfortable
life? In olden days, comfort was expected and physicians did not expect
to get rich, but the moderate degree of comfort was complemented even
more by the twin towers of prestige and individualism — the ability of
the individual to make decisions, after weighing all the information
deemed necessary, by due and deliberate cogitation.
The prestige once granted by society to the physician continues to erode,
as shown by Paul Starr and others. People who put us on pedestals are
surely, and not slowly, lowering us, ably abetted by the sensation-seek-
ing, thought-rejecting press and film. As a result, the erstwhile rec-
ommendation to an aspiring princess to marry a doctor, or, even better,
to have one for a father, no longer pertains. In today’s world, the doctor
may well be a woman, a situation long overdue. The doctor’s hours can
be long and unpredictable; parents with nice businesses can give longer
and better quality hours to their children. In the acquisition-minded
decade of the 1980s, there were easier ways to make big bucks than in
medicine. And government in the decade of the 1990s seems poised to
place a cap on all types of physician income.
We may not be able to act as individualistically as in the past, but at
least we shall retain the ability to make the final decisions — to treat or
not to treat, how to treat, and when to treat. Right? Sorry! In addition
to the pressures we have been enduring from insurance companies and
government regarding length of stay and appropriateness of care, we soon
are to be further shackled by members of our own profession, who will
establish the cookbook of medicine — the recipes that are intended to turn
practitioners into medical escoffiers, but are more likely to produce
short-order cooks.
Medicine has long been recognized as both an art and a science, travelled
along many parallel, but separate, paths toward proper diagnosis and
treatment. Many differences also develop between the specific and the
general. It has been shown that general principles of investigation or
treatment often are bent or fractured when dealing with individual
patients, sometimes by omitting and sometimes by adding too broad
recommendations. These differences in approach are striking, signifi-
cant, and reproducible and suggest that medicine, as practiced by
reasonable physicians, demands flexibility.
We used to have criteria of care for hospital admission, inhospital care,
and discharge. These criteria employed during the almost-forgotten days
of cost-plus accounting were abandoned quietly and quickly when the
screws of cost-containment began to turn. (Can you imagine that once —
not long ago — we required that postoperative hernia patients were
afebrile and that all body functions, including bowel, had returned to
normal before discharge was considered appropriate?)
Yours truly once was privileged to debate many of the reports of the
AMA’s Council on Scientific Affairs at reference committee hearings and
VOL. 87— NUMBER 6 JUNE 1990
459
EDITOR’S DESK
on the floor of the House of Delegates. Despite disclaimers appended
to each accepted report, intended to act as a brake against unwarranted
use of the standards in litigation, there was great worry about this
possibility. This worry certainly has deepened through the years. One
shall have even more concern when one notes some of the reports were
adopted as AMA policy by bare majority vote — just enough to plant a
policy into plaintiff s fields of endeavor. We have been reassured that
standards or parameters of care should not impose additional and un-
reasonable burdens on defendant physicians and may even decrease the
vagaries of jury response. So saith the AMA and its legal counsel. Those
of you who agree with this assessment please write; somehow we do not
expect to be overwhelmed by responses.
Algorithms are helpful. Computer analyses are helpful. Bright physi-
cians practicing both the art and the science of medicine for the benefit
of their patients certainly can use modern techniques to aid their de-
liberations. But standards or parameters proposed by government and
organized medicine can boobytrap even the most caring physician. They
will certainly be used by government, by its contracted review agencies,
e.g. PROs, and by plaintiffs and their legal representatives. All of these
groups love statistics and love its attendant publicity. The physician,
already overburdened by bureaucratic paperwork, will have a choice —
be innovative and face additional sanctions and legal expenses, or be-
come a cookbook doctor. If enough follow the second course, we may
enter the age of robotic medicine, especially for those who exhibit few
or no procedural skills. For them, the RBRVS may have to develop
downgraded fees, their cognitive skills having been so eroded by the blind
following of recommended recipes that they are treating by the numbers.
“The discovery of a new dish does more for the happiness
of mankind than the discovery of a star. ”
Anthelme Brillat-Savarin, Physiologic du gout (1825)
460
NEW JERSEY MEDICINE
a$s
BOOK
REVIEWS
ALLERGY AND ASTHMA:
NEW TRENDS AND
APPROACHES TO
THERAPY
A.B. Kay (ed). London, England, Blackwell Scientific Publications,
1989. Pp. 277. The book brings together the rapid development of new
forms of therapy for bronchial asthma and other atopic disorders (IgE-
mediated) that are among the most active areas of medical research
today. The organization of the text has been developed to advance the
traditional treatment approaches, i.e. allergy and avoidance, antiallergic
drugs, and immunotherapy. The first section details the formation of
actual lipid mediators and their inflammatory involvement in allergic
responses. This section goes on to devote an entire chapter to the phar-
macological modulation of IgE-mediated generation and the allergic
response by the famous ‘omega’ (fish oil diets). The second section
delineates the process for modulation of the specific immune response
in allergic disorders, and provides further analysis of the possibility of
suppressing the IgE response with various types of proteins developed
by biotechnology, e.g. suppressive factor of anaphylaxis. In part three,
specific medications that suppress inflammation are discussed, such as
cetrizine, a selective HI antagonist that affects various inflammatory
cells, specifically eosinophils; the long-lasting azelostine, a compound
with multiple modes of action; and nedocromil sodium, an antiasthmatic
drug with steroid sparing effects.
The book does accomplish its goal in developing a rational approach in
the new trends and approaches in allergy and asthma therapy and should
be of interest to allergists/immunologists, pulmonologists, internists, and
family practitioners interested in IgE-mediated disorders. □ Leonard
Bielory, MD
CECIL ESSENTIALS OF
MEDICINE
Thomas E. Andreoli, MD. W.B. Saunders Company, Philadelphia, PA,
1990. Dr. Thomas E. Andreoli, professor and chairman, Department of
Internal Medicine, University of Arkansas College of Medicine, and chief
of medicine, University of Arkansas Hospital, and other highly qualified
medical editors have been responsible for this scholarly second edition.
The text contains 12 major sections focused either on different organ
systems or on disease groups sharing a common theme, such as infectious
disease, neoplastic disease, or congenital diseases.
The name of Cecil on any textbook heading as editor, ever since the early
part of this century, has been considered as a mark of excellence in
editorial scholarship in the field of general medicine.
The attempt here was to renew and advance the efforts of the prede-
cessor, Cecil Textbook of Medicine, in a succinct readable text, and to
cover the important elements of the principles and practices of the broad
field of internal medicine in a concise manner. Each chapter contains
the latest available information and is complete with an index of timely,
recent references.
Essentials does not intend to duplicate any other Cecil textbook but
hopes to provide a core or summary for students of medicine during their
undergraduate medical clerkships or in review preparation for exami-
VOL. 87— NUMBER 6 JUNE 1990
463
BOOK REVIEWS
nations. Cecil Essentials of Medicine, Second Edition also is highly
recommended for a place on every physician’s desk, to replace older
reference texts on similar subjects. □ Harry M. Poppick, MD
NUCLEUS OF
CARDIAC DIAGNOSIS
William A. Schiavone. Philadelphia, PA, Lea & Febiger, 1990. This
softcover book is a collection of vignettes garnered from the author’s
experience at the Cleveland Clinic. While the declared purpose is “to
teach the utility of the electrocardiogram and the chest x-ray,” the
reader will find the brief case reports more amusing than instructive.
Adorned by such sexy titles as “The Syncopal Secretary, Amply En-
dowed and the Effusive Nun,” the selected cases deal with a variety of
cardiac disorders in a superficial fashion. Conventional chest x-rays are
nicely reproduced, but some of the electrocardiograms are difficult to
interpret because of poor contrast.
This book, not intended for the experienced cardiologist or the serious
student, does help to restore confidence in the diagnostic value of two
readily obtained, noninvasive, and inexpensive tests. □ Edwin L.
Rothfeld, MD
THE OCULAR FUNDUS
Manfred R. Tetz and David J. Apple. Philadelphia, PA, Williams and
Wilkins, 1990. This book is an atlas that provides high-caliber documen-
tation of most common and some rare retinal and fundal diseases. The
photographs are accompanied by case reports, many of which show
sequential changes during the course of the disease. The descriptions of
numerous retinal diseases are concise and easily understood, that along
with good photographs aid in the comprehension of these conditions.
Those capable of using an ophthalmoscope will find recognition of retinal
diseases can be simplified by studying and using this book as a guide.
There also is an excellent bibliography for those interested in reviewing
the subject. □ Alfonse A. Cinotti, MD
TUBAL
RECONSTRUCTIVE
SURGERY
Ginter Sotrel. Philadelphia, PA, Lea & Febiger, 1990. Medical science
has risen to the challenge posed by the near epidemic of sexually trans-
mitted diseases (STD) that have damaged Fallopian tubes and com-
promised the fertility of increasing numbers of young women by discover-
ing new instruments and techniques designed to correct the damage.
Doctor Sotrel, with contributions from three colleagues affiliated with
Boston University School of Medicine, has presented a comprehensive
textbook covering all aspects of reconstructive surgery, including
thorough explanations and excellent illustrations. At first glance, this
book might seem valuable only to those gynecologists interested in re-
constructive tubal surgery, but after more careful perusal it is obvious
this book will be valuable to every primary care physician encountering
patients eager to achieve a successful pregnancy after a bout or two of
STD, ectopic pregnancy, and/or sterilization.
The sexplosion of the 1960s has reaped its harvest of increased infertility
through more opportunities and more years to contract STD and has
created increased numbers of second or prospective husbands eager for
offspring from sterilized women. This book will enable clinicians to
differentiate those patients with potentially correctable tubes from those
patients who immediately should consider alternate methods of assisted
conception. Although an indepth treatment of this latter subject is
beyond the scope of this book, enough information is presented to the
reader so that clinicians can intelligently advise patients of all of their
options. This book is recommended without qualification. □ Jerome
Abrams, MD, MPH
464
NEW JERSEY MEDICINE
Z LETTERS &
VIEWPOINTS
BABESIOSIS I would like to thank Sandra W. Moss, MD, for her fine article, “Long
Odyssey of Babesiosis,” in the April 1990, issue of NEW JERSEY
MEDICINE. It was especially timely for me because in August 1989,
I admitted a patient to The Medical Center at Princeton with that very
condition. Interestingly, she had contracted babesiosis while spending
the summer in Nantucket, an endemic area for this parasite. This pa-
tient also had coexisting Lyme disease, a condition also endemic to
Nantucket and carried by the same vectors.
I believe Dr. Moss’s article also should be timely for other physicians
in New Jersey because as we approach the summer months, when the
tick vector for babesiosis is so active, we must all be aware that Nan-
tucket, a favorite summer resort, is only a few hundred miles from our
state. □ R. Michael Roberts, MD
WOMEN IN The editorial in March 1990, “Hippocrates’ Rib,” would have been
MEDICINE infinitely more constructive had the editor recommended women join
both the American Medical Women’s Association (AMWA) where they
can enrich themselves personally, and the American Medical Association
(AMA) where they can educate and sensitize male colleagues — physi-
cians and editors — in order to achieve a truly equal partnership in medi-
cine.
Unfortunately, many issues that are mainstream agenda items of
AMWA and its New Jersey branch, have been relegated to the Commit-
tee on Women in Medicine of the Medical Society of New Jersey
(MSNJ), and never find their way onto the MSNJ agenda. Having
attended a number of the MSNJ trustees’ meetings this past year in
my capacity as president-elect of New Jersey Medical Women’s Associa-
tion (NJMWA), and having read MSNJ written materials and minutes,
I note little concern about those societal issues that impinge on women’s
ability to participate in the practice of medicine.
For example, combatting sexual harassment could be a great goal for
MSNJ. While NJMWA and the MSNJ Committee on Women in Medi-
cine are planning to cosponsor a seminar, “Sexual Harassment in the
Workplace,” in September 1990, would it not be an appropriate and
marvelous show of support to have a large attendance of male colleagues?
Let MSNJ show its sensitivity by applying its resources to address this
problem, to educate medical professionals who work in hospitals and
offices to provide easily accessible avenues for female physicians (includ-
ing students and residents) to register complaints with the Society and
to obtain supportive action from your excellent legal consultants when
needed.
Another associated problem for women physicians is discrimination in
the workplace. Many women have experienced discrimination in overt
and subtle ways — such as being denied professional opportunities in
private practice and promotions in institutional hierarchies, being of-
fered reduced salaries relative to men, or being excluded from the referral
VOL. 87— NUMBER 6 JUNE 1990
467
LETTERS & VIEWPOINTS
networks of their male colleagues.
Some students and residents with young families require child care
facilities in order to pursue medical careers uninterrupted, during this
age of dual-career families. MSNJ can use its influence to develop
programs that address these needs in hospitals and other medical institu-
tions.
Some women need alternative residency and work programs due to
family needs. The medical profession and our patients would benefit
greatly from the manpower and talent of those women who can supply
services on a limited basis. Let residency and job opportunities for
women be a mainstream agenda item for AMA and MSNJ. Show women
that MSNJ is actively fighting discrimination. Extend our fight against
discrimination to include other minority groups. Let us refocus organized
medicine’s concerns somewhat to consider these important social issues,
and perhaps our profession will begin to appear more humane in the
public eye as well.
Do not try to deny women the benefits of AMWA. Whereas male phy-
sicians meet and network at tennis, golf, and eating clubs, in the chang-
ing rooms of hospitals, and at organizational meetings, women have very
little opportunity for professional and social networking. New Jersey
Medical Women’s Association provides a milieu for women to network,
build friendships, share common experiences and problems, and develop
leadership potential in our organization, whose agenda matches their
own. Why should that threaten the AMA?
Show women physicians that MSNJ is not simply calling for their par-
ticipation because of lagging membership but because of a sincere
interest in their welfare. Many women belong to both organizations, and
that is commendable. AMWA encourages its members to join and par-
ticipate in AMA and relevant specialty societies. Pulling together, we
can all be strengthened. □ Sandra Samuels, MD, President-Elect, New
Jersey Medical Women’s Association
EDITOR’S REPLY Dr. Samuels’s letter is greatly appreciated. The issues she raises certain-
ly warrant the most careful consideration by all in organized medicine.
But there seems to be some misconceptions expressed in her letter about
our attitudes and positions.
As we noted, participation in club-like activities does not give a person
a vote in policymaking organizations: that is why we encourage greater
participation in county and state medical societies and in the AMA.
Women do not have to belong to either AMWA or the AMA — to one
or the other; they are not mutually exclusive memberships. It also would
be helpful for the members of MSNJ’s Committee on Women in Medi-
cine to participate more fully and in greater numbers, in order to punctu-
ate the important issues sent to a most caring Board of Trustees.
We need the enormous potential of women to be tapped — not for “your”
benefit, not for “our” benefit, but for the benefit of all of us, male
physician, female physician, and the American public as a whole. We
cannot waste this resource during these difficult times. □ Howard D.
Slobodien, MD
LETTERS TO Letters to the editor-in-chief of NEW JERSEY MEDICINE are wel-
THEi EDITOR come- Communications should be sent to NEW JERSEY MEDICINE,
the Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648. Style information is noted on page 509.
468
NEW JERSEY MEDICINE
Inaugural Address
DOUGLAS M. COSTABILE, MD
Dr. Costabile, the 198th president of the Medical Society of New Jersey,
presented this speech on Monday, May 7, 1990, at the 224th Annual Meeting
of the Medical Society of New Jersey.
I would like to acknowledge those people who
have served in this post in previous years and
still are contributing to the work of this or-
ganization. That illustrious company includes Doc-
tors Joseph Jehl, Nicholas Bertha, William D’Elia,
James Rogers, John Madara, Charles Krueger,
Alfred Alessi, Augustus Baker, Howard Slobodien,
Alexander Kovacs, Frank Watson, Ralph Fioretti,
Edward Schauer, Harry Carnes, Palma Formica,
and Paul Hirsch. I have big shoes to fill.
Every year this body elects a new president and,
every year, the individual receiving that great honor
stands before you and tells you how he or she hopes
to improve the climate in which we practice our
profession.
Well, this year Pm the guy and I am no different
than all the rest. I hope to improve the climate in
which we practice because that is part of what the
Medical Society of New Jersey is all about.
We, in all honesty, are here to protect an exposed
portion of our anatomy. In that, we are no different
from the AFL-CIO or the American Association of
Manufacturers — with one notable exception.
Our profession is the profession of saving lives.
That is what we do for a living. We bring babies into
the world, we attempt to cure illness and overcome
trauma, and, when necessary, we ease the pain of
those we cannot cure.
Therefore, the nature of our profession is different
and our ability to protect ourselves from the slings
and arrows of outrageous fortune, to say nothing of
federal and state regulation, is compromised.
We are blamed for lack of quality of our work as
well as perceptions, often incorrect, relative to the
lack of quality. We are blamed for the high cost of
our work even though we do not garner all or even
the largest portion of the profits of that work. Expec-
tations are that (1) we should be able to prevent all
illness; (2) that if anyone does become ill, we should
be able to cure him with one office visit or, better
yet, one house call; and (3) we should not charge for
this service.
We are physicians, not magicians. We are mortals,
not Merlins. As mortals, we do a difficult job — we
VOL. 87— NUMBER 6 JUNE 1990
471
do it well — we don’t have to apologize for it and we
don’t have to apologize for making a decent living
at it.
Sadly, there are those among us who are
mercenary. They overcharge for what they do and
they do things they shouldn’t do. There are those
among us who are incompetent. They are few and
most of us have the intestinal fortitude to call them
to account.
We get little credit for the good we do. In 1987,
a study was done by the AMA and the American
Hospital Association that showed that three out of
five physicians provide care for the indigent and
those lacking insurance coverage. Physicians devote
an average of one-half day per week to the provision
of charity care. Translated into dollars, the average
physician forgoes $16,900 annually in net income to
provide care for the poor.
Does it win you any medals? Absolutely not. Does
the average patient know what you do for charity?
Absolutely not. And if he were told, he wouldn’t
believe it. I told a patient of mine that three out of
five doctors provide charity care and he asked me,
“What about the other two guys?”
So if you are looking for a pat on the back, forget
it. You do it and you will continue to do it for one
reason only. It is the right thing to do.
Well, what else can we do about that anatomical
exposure of which I spoke? We can improve our
public posture by working on some aspects of our
professional lives that upset our patients. Do you
know what the number one complaint is that the
average patient makes about his doctor — more often
that the cost of treatment? It is being kept waiting
at the office. What you are saying in effect to that
patient or, at least, what he is hearing, is that I, the
physician, am more important than you, the patient .
My time is valuable — yours is not. They don’t like
that message and I don’t blame them.
Now, we can do something about that. We can
start our hours on time and make sure that our office
staff doesn’t overbook us. With some doctors, it’s an
ego trip to have a full waiting room. Are we so in-
secure that we need to do that?
For those inevitable delays, and they happen now
and then, what is wrong with having your assistant
explain to the patient that you are delayed and his
appointment will be late? That is common courtesy
and we don’t practice it enough.
Also, why don’t we make videotapes to be shown
in our waiting rooms with details of our practices.
The tapes could explain office routine, or insurance
forms, or the ailments commonly treated by our
specialty.
If a patient must wait for you, let them get some-
thing in your waiting room besides “General Hospi-
tal” or “Days of Our Lives.” Let us get away from
the old magazine syndrome and make that waiting
time productive for our patients. The public rela-
tions benefit will outweigh the cost.
That is individual, personal, hands-on, doctor-
patient communication.
There are other serious problems that we cannot
solve in our office. We move closer every day toward
some system of nationalized medicine. There are two
reasons why such a system has not yet been
promulgated in this country; one is the average
citizen is not convinced that any system of rationed
care is in his best interest — not yet.
The other reason is organized medicine. A lot of
us are critical of the AMA, MSNJ, and our county
societies, and not completely without reason. These
organizations are not perfect. But, for all the mis-
takes they make, they still represent you at every
level of society and they do it as well as they can
with limited staff and with members who generally
are nonparticipants, except to complain.
What they need to operate even better is not just
your dues, important as they are, but your commit-
ment. They need your willingness to march in Tren-
ton or Washington for what you believe.
They need you to stand together as a body — not
to defend your income but to defend the finest sys-
tem of medical care in the world.
They need you to sit down together to develop
programs to ensure no one is left out of that system
because they have no money. They need you to com-
mit yourself to the poor of your country, your state,
your county, and your city. Unwed pregnant women,
neglected children, the victims of AIDS, and the
victims of drugs — to the minority patient — they all
need our help and our service.
Don’t say you don’t have time and that it is some-
one else’s problem.
Make time.
It is your problem because you are a human being
and you have special skills. You can start solving
society’s problems by reaching out to those w-ho were
not born as talented as you, or as financially secure
as you, or who lack the desire to work as hard as
you do.
We are not all created equal — those of us in medi-
cine know that better than anyone else. We were
blessed with special talents and we were able to
make the most of them.
If we do not help to solve these problems, we will
not be happy with the solutions others will impose
upon us. Most important, we have to do it because
it is the right thing to do.
Let us begin now to recommit ourselves to the
values that brought us into this difficult, demand-
ing, and rewarding profession in the first place.
Let us care. Let us do no harm. Let us make a
difference. ■
472
NEW JERSEY MEDICINE
Panic Disorder
and Agoraphobia
MORTON FIER, MD
Panic disorder and agoraphobia present in varied forms, yet the avoidant
defenses remain remarkably similar. The author describes three cases of
panic disorder; the symptoms relate to fear of loss of bowel control.
In recent years, the interest in the diagnosis and
treatment of panic disorder and agoraphobia
has grown exponentially. As early as 1989,
Sheehan and associates estimated that as many as
12 million Americans were suffering from panic dis-
order.1 As interest in the disorder has grown, and the
diagnosis refined, it is safe to say that significantly
more than the estimated 12 million people are
burdened by the symptoms. DSM-III-R lists a series
of 13 possible somatic symptoms that may occur
during a panic attack: dyspnea, dizziness, palpita-
tions or tachycardia, trembling, sweating, choking,
nausea or abdominal distress, depersonalization or
derealization, numbness or paresthesias, flushes or
chills, chest pain, fear of dying, and fear of loss of
control.13
Many patients present at hospital emergency
rooms with 1 or more of these 13 symptoms. Medical
evaluation generally fails to reveal any organic basis
for the symptoms. A patient typically has an ex-
tensive workup that can include a stress test,
echocardiogram, computed tomography scan, mag-
netic resonance imaging procedure, electroenceph-
alogram, electrocardiogram, laboratory tests, and
Dr. Fier is director of psychiatric inpatient services,
Hackensack Medical Center and clinical professor of
psychiatry, UMDNJ-New Jersey Medical School, Newark.
The manuscript was submitted in January 1990, and
accepted in March 1990. Requests for reprints may be
addressed to Dr. Fier, 140 Prospect Avenue, Suite 4,
Hackensack, NJ 07601.
calorics. In addition, consultations with neurol-
ogists, cardiologists, internists, and otolaryngol-
ogists are part of the extensive evaluative process.
Lydiard and colleagues reported five patients with
panic disorder and irritable bowel syndrome; symp-
toms resolved with antipanic treatment.3 These
authors suggest “a proportion of patients who are
being treated for irritable bowel syndrome, in fact,
may suffer from a panic-related disorder. Avoidance
behavior and anxiety associated with symptoms con-
sistent with irritable bowel syndrome should raise
the clinical suspicion that a primary anxiety dis-
order may exist.”
The myriad ways in which the defenses against
panic attacks are presented continue to fascinate
and challenge the clinician.4-5 In evaluating patients
for the diagnosis of possible panic disorder, the clini-
cian must not only focus on the symptoms of the
panic attack, but must be alert to the defensive
avoidance of situations believed to precipitate at-
tacks, and the preference of the agoraphobic to re-
main at home. The three case reports presented here
demonstrate an unusual presentation of panic dis-
order, agoraphobia, and gastrointestinal complaints.
CASE REPORT 1
A 34-year-old, married, white female had gall-
bladder surgery six months prior to seeing me (No-
vember 1988). One year earlier, she had a baby,
delivered by cesarean section; a few months after
VOL. 87— NUMBER 6 JUNE 1990
475
giving birth, the patient was diagnosed as having
Hashimoto’s disease.
Two weeks after gallbladder surgery, the patient
developed “stomach pains” and the need to fre-
quently use the toilet. She became preoccupied with
the need to be near a bathroom and became increas-
ingly anxious and frightened away from home:
“What if I have to go and there is no available
bathroom?” When seen in psychiatric consultation,
she was agoraphobic and unable to leave home; she
demonstrated vegetative signs of depression. Her
mother-in-law and mother were in constant atten-
dance during the day so that an adult would be
available to watch the baby, should the patient need
to go to the bathroom.
The diagnostic impression was agoraphobia with
secondary depression. The patient was treated with
imipramine 25 mg at bedtime, increased to 50 mg
at bedtime one week later. She tolerated the medi-
cation well and within three weeks was totally symp-
tom-free and planning to return to work as a com-
puter specialist with a bank.
CASE REPORT 2
A 58-year-old, married, white male executive, had
been involved in an automobile accident in which
his car was “totalled.” The patient was uninjured,
but one year later he developed panic attacks. The
patient was seen by a colleague in psychotherapy for
several years without much benefit. He demon-
strated many of the usual features of agoraphobia,
e.g. fear of tunnels, bridges, traffic jams, and mov-
ies. In addition, when away from home, he constant-
ly felt the urge to defecate. On work days, he arose
at 4 A.M. and spent hours on the toilet, in the hope
that he would completely empty his bowels, and
thereby, obviate the need for further toileting. How-
ever, as soon as he left home he again felt the need
to defecate and feared if he did not find a toilet
quickly that he might soil himself. He carefully
mapped out the route to work so that he would have
ample access to public bathrooms and stopped three
to four times on a 30-minute drive. He was most
comfortable at home and avoided leaving home as
much as possible. The diagnosis was panic disorder
with agoraphobia. He was treated with imipramine,
up to 300 mg daily. He felt somewhat better, but
found the anticholinergic side effects intolerable.
The patient then was treated with phenelzine
(Nardil®) to 75 mg daily. He experienced significant
1. Sheehan DY, Claycomb JB, Kouretas N: Mono-
amine oxidase inhibitors: Prescription and patient man-
agement. Intern J Psychiat Med 10:99-121, 1980.
2. Diagnostic and Statistical Manual of Mental Dis-
orders. Washington, DC, American Psychiatric Associa-
tion, 1987.
symptom relief but developed sexual dysfunction.
The dose was reduced to 60 mg daily and then to
45 mg daily with continued symptom relief and dis-
appearance of the sexual difficulties.
CASE REPORT 3
A 45-year-old married male had a history of diar-
rhea since 1970; he felt the diarrhea was a stress-
related symptom. Complete workup by a gastroen-
terologist failed to establish an organic etiology for
the symptoms. Several years ago, while on a bus that
was stuck in a tunnel, he had a frank panic attack
for fear he might soil himself. He was obsessively
preoccupied with thoughts of “What if I have to go,
and there is no bathroom available?” He developed
typical agoraphobic defenses, e.g. anxiety in a
barber’s chair, restaurant, and shopping malls. In
theatres, he always chose an aisle seat so that if
panicked, he could leave instantly. He was most
comfortable at home and preferred not to leave.
With a diagnosis of panic disorder with agora-
phobia, the patient was started on imipramine 25
mg at bedtime, increased to 50 mg at bedtime. He
felt sedated, lethargic, and apathetic, and was un-
able to tolerate the anticholinergic side effects. The
patient was switched to phenelzine (Nardil®) and
gradually increased to 75 mg daily. At that dose, he
was almost free of agoraphobic symptoms. He had
occasional exacerbation of anxiety when forced to fly
on business trips. He stated he was not 100 percent
symptom-free at the present time, but felt signifi-
cantly improved.
DISCUSSION
The three case reports, though not typical in the
presentation of symptoms, all responded to standard
treatment for panic disorder and agoraphobia. The
clinician who sees patients complaining of anxiety
must be careful to distinguish between generalized
anxiety disorder and panic disorder. Though panic
disorder and agoraphobia often present in a wide
variety of symptoms, e.g. hyperventilation, chest
pain, and bowel dysfunction, the defensive structure
is amazingly similar. Whatever the symptoms, pa-
tients are most comfortable at home, avoid going
out, and especially avoid situations in which they
feel trapped. Treatment with imipramine or
phenelzine generally produces dramatic improve-
ment. ■
3. Lydiard RB, Lacara H, Ballinger JC: Can panic dis-
order present as irritable bowel syndrome? J Clin Psychiat
47:470-473, 1986.
4. Fier M: Agoraphobia, the “what if’ syndrome. J Med
Soc NJ 78:286-288, 1981.
476
NEW JERSEY MEDICINE
Claustrophobia During
MR Imaging
ROGER B. GRANET, MD
LAWRENCE J. GELBER, MD
Magnetic resonance imaging (MR!) is an effective diagnostic radiologic
procedure with a wide margin of safety. The authors describe the
phenomenology and etiology of claustrophobia during MR! and provide an
integrative management approach for referring physicians, radiologists, and
technicians who deal with this difficult problem.
Magnetic resonance imaging (MRI) is a
valid, reliable, noninvasive radiologic
procedure for the examination of struc-
tural pathology. With a wide margin of safety, in-
cluding the lack of exposure to ionizing radiation, its
utilization appears benign in regard to patient
morbidity. However, MRI does present difficulty for
a number of patients. In particular, the psychologi-
cal experience of claustrophobia, the fear and at-
tendant anxiety associated with closed spaces, is a
dysphoric reaction for many individuals. Initial data
Dr. Granet is director, consultation-liaison psychiatry,
Morristown Memorial Hospital; clinical associate pro-
fessor of psychiatry, Cornell University Medical College,
New York; and associate attending psychiatrist, The New
York Hospital-Cornell Medical Center. Dr. Gelber is af-
filiated with the Tri-County MRI and Neurodiagnostic
Group of New Jersey, PA, Chatham. This manuscript was
submitted in November 1989 and accepted in January
1990. Requests for reprints may be addressed to Dr.
Granet, 20 Community Place, Morristown, NJ 07960.
suggested that 5 to 10 percent of patients ex-
perienced claustrophobia during MRI.12 Subse-
quently, Brennan et al. reported that 35 percent of
patients while undergoing MRI experienced anxiety,
with the inability to move, length of procedure, size
of the tunnel, and the feeling of being closed in, as
the primary correlates of the anxiety.3 Quirk et al.
reported a series of exit interviews of patients who
completed MRI.4 Of those interviewed, 65 percent
experienced anxiety or claustrophobia. In addition,
42 percent reported that they received little or no
information about the procedure from the referring
physician. In another study, Fishbain et al.
documented several cases of long-term, delayed-
onset claustrophobia, that occurred following the
imaging procedure.5
Given the increased utilization of this radiologic
technique and the significant incidence of
claustrophobic reactions, this paper provides infor-
mation for referring physicians, radiologists, and
VOL. 87— NUMBER 6 JUNE 1990
479
technicians. The phenomenology and etiology of
claustrophobia in the MRI setting will be reviewed
and an integrative management approach drawing
upon biological, behavioral, and psychodynamic
treatment strategies will be described.
PHENOMENOLOGY OF CLAUSTROPHOBIA
Claustrophobia is the persistent fear of being
locked or shut-in and the fear of enclosed places.6
The clinical expression of fear is of anxiety that may
be central (psychic), i.e. a subjective sense of doom
or apprehension; and peripheral (somatic), an
adrenergic “surge” presenting with palpitations,
tremulousness, xerostomia or sialorrhea, gastroin-
testinal discomfort, and sweating. The prevalence of
this phobic reaction might be viewed on a bell-
shaped curve with most people experiencing the sen-
sation at one time or another, i.e. a normal variant
and to a smaller number of individuals, it is a
chronic, persistent, debilitating pathologic reaction.
There are three components to a claustrophobic
reaction applicable to the MRI setting:7 anticipatory
anxiety precipitated by the possibility of being
trapped or shut in the tunnel; central fear, i.e. in-
tense anxiety experienced during the procedure; and
avoidant behavior, such as refusing or prematurely
terminating the procedure to decrease the anxiety.
It should be emphasized that claustrophobia is not
a fear of the object but more the potential negative
outcome or consequence of being in the setting. In
addition, most individuals who experience such
phobic reactions realize the fear is irrational.
ETIOLOGY OF CLAUSTROPHOBIA
The causes of claustrophobia during MRI may be
viewed from biological, behavioral, and psy-
chodynamic perspectives. One biological theory is
the concept of evolutionary prepared learning.8 This
theory suggests that claustrophobia may have in-
volved stimuli that historically may have rep-
resented a danger to man, and still are reacted to
as if they are dangerous. In the MRI setting, the
Claustrophobia
The persistent fear of being locked or
shut-in, and the fear of enclosed
places.
Nuclear magnetic resonance
Noninvasive radiologic procedure for
the examination of structural
pathology.
sense of being “trapped” may have an evolutionary
antecedent precipitating a perceived physical
danger. Another biological theory postulates that a
claustrophic reaction may be a function of aberrant
neurotransmitter activity. For example, Liebowitz
et al. have discovered elevated levels of epinephrine
in some phobic individuals.9
The behavioral or conditional reflex theory views
claustrophobia as an acquired, as opposed to an in-
nate, behavior."1 The phobia is seen as a conditioned
response learned through the association of the
phobic object, the MRI, with a noxious experience,
or traumatic event.
Finally, there is the psychodynamic theory of
claustrophobia. Freud argued that a phobia was a
symptom of unresolved unconscious drives and con-
flicts." A phobic symptom such as claustrophobia,
might represent a conflict between aggressive or sex-
ual impulses and the recognition that the expression
of such an impulse might be met with external
danger. In the MRI setting, the danger might be
displaced onto the radiologic equipment. A less or-
thodox Freudian perspective would argue that
claustrophobia is an anxiety reaction tied to the fear
of losing control of something, i.e. the fear of losing
control of one’s “mind” and “going crazy.”
A specific application of psychodynamic theory in
the MRI setting relates to the unconscious defense
mechanism of displacement. Often a patient re-
ferred for MRI is understandably fearful that some-
thing is “wrong” or “dangerous” in the body in the
form of a disease. The patient might displace that
fear from his body to the equipment and become
frightened of it.
INTEGRATIVE MANAGEMENT APPROACH
Given the variable clinical presentation and the
multidetermined etiology of claustrophobia during
MRI, the referring physician, radiologist, and tech-
nician are faced with the challenge of being helpful
to the phobic patient. An integrative management
approach is offered to help the professional deal with
such individuals. (Table).
Several general guidelines might be considered.
Through both the literature and impressionistically,
it would appear that the fear of losing control is a
central dynamic for the claustrophobic individual.
Such people are further compromised in the MRI
setting since they anticipate the procedure will de-
termine if, in fact, there is something “wrong” or out
of control inside their bodies, i.e. medical disease.
In addition, patients are placed in an emotionally
and physically dependent position, further increas-
ing their helplessness and potential regression. All
energies should be directed towards giving these pa-
tients control. A related issue is knowing when to
respect a patient’s defenses such as denial and re-
480
NEW JERSEY MEDICINE
pression. By definition, defense mechanisms are
protective. If a patient is not open to discussion and
appears to be adapting to the MRI stressors, not
focusing on anxiety or stress may help him feel in
control. In other words, at times, no intervention by
those performing the procedure is useful and per-
ceived by certain patients as reassuring and nonin-
trusive.
Another management strategy is education. One
component is preprocedure counselling provided by
the referring physician, radiologist, or technician.
Patients might be asked for a history of claus-
trophobia. They must be reassured this is a common
phenomenon, they are not “crazy,” and everything
will be done to ensure their comfort. They should be
given information concerning the procedure. This
educational process might focus on areas of safety
such as the noninvasiveness of the technique, or the
lack of exposure to ionizing radiation. In addition,
a description of the procedure (of being placed in the
tunnel, the amount of time they might be in the
tunnel, and an explanation that the changing
magnetic gradients cause “banging”) should be of-
fered. Additionally, patients should be reminded
that the apparatus generates heat and they may
experience a sensation of thermal discomfort. Also,
after the procedure, claustrophic patients might be
given the opportunity for catharsis and “debriefing.”
This also provides an opportunity to positively rein-
force a difficult experience.
During the procedure itself, support and re-
assurance are critical to minimize phobic anxiety.
Patients must be given ultimate control by letting
them know they are able to discontinue the pro-
cedure if necessary. Clinically, it has been observed
that patients can maintain control with a handheld
panic button. Paradoxically, once given the per-
mission to do so, it rarely is necessary. Constant
emotional support, with noninfantalizing feedback
and reassurance that the patient is in the hands of
a competent professional is most useful. If the pa-
tient begins to experience anxiety, gentle limit set-
ting so he can tolerate the discomfort often is help-
ful. This often can be accomplished by informing the
patient that the examination consists of, depending
on the type of study, approximately four sequences
each lasting between five and ten minutes and that
if he can tolerate even the first sequence, it may be
diagnostic. Often, the patient then will be able to
proceed with the second sequence. Beginning with
the sequence that is most likely to be diagnostic will
be helpful to the radiologist in case the examination
must be terminated prematurely.
Specific environmental manipulations have been
described that attempt to increase the level of ex-
ternal stimuli. Ellis et al. reported the use of patient
blinders or complicated maneuvers such as using
compressed air to transmit music through the head-
phones.'2 They describe these interventions as time
consuming and not particularly effective. Today,
there are nonferrous components available, allowing
patients the use of headphones within the scanning
bore. Patients are encouraged to bring cassettes that
serve to increase the familiarity of this often fright-
ening MRI setting as well as lessen the negative
impact of the “banging” created by rapidly changing
magnetic gradients. Hricak and Amparo have used
a patient positioning technique that appears quite
useful.1-1 Noting that the supine position, with the
resultant inability to see either end of the bore, leads
to increased darkness, the authors suggested a
simple approach of placing the patient in a prone
position with the chin supported by a pillow, so the
patient’s eyes face the opening of the bore. In this
manner, the patient sees light and the presence of
others in the external environment. One potential
Table. An integrative management approach.
General Guidelines
Theme of control
Respect of defenses
Education
Preprocedure Counselling — Explanation:
safety, expectations
Postprocedure Counselling — Debriefing,
catharsis, reinforcement
Support and Reassurance
Emotional support
Reassurance
Gentle limit setting
Environmental Manipulation
Patient blinders/music
Prone positioning
Fans
Prism glasses
Companions
Behavioral Techniques
Imaginal exposure
Fantasy
Medication
Benzodiazepines
Beta-blockers
VOL. 87— NUMBER 6 JUNE 1990
481
problem with this approach is that many surface
coils are designed for the supine position. There are
other techniques to accomplish these same goals
while maintaining the supine position. These in-
clude a large light at one or both ends of the bore
and the use of nonferrous prism glasses that permit
the patient to see out of one end of the bore. In
addition, some units allow the presence of a fan at
one end of the bore contributing a different kind of
external stimulus. Finally, one of the more success-
ful ways of changing the MRI setting, to lessen pa-
tient anxiety, is to allow a friend or family member
to be in the scanning room. The companion can hold
hands or feet, carry on conversation, or be positioned
to be seen with the aid of prism glasses, through the
end of the bore.
For intensely claustrophobic patients who have
refused or failed to tolerate MRI, the behavioral
technique of imaginal exposure may be of use. First,
the patient is taught relaxation techniques such as
slow, deep breathing, and muscle relaxation and
then instructed to think of the machine. The com-
bination of being relaxed while thinking of MRI
might help extinguish the fear. Klonoff et al. re-
ported a useful behavioral technique that included
a specific systematic desensitization to be practiced
at home, prior to MRI.14 A related behavioral tech-
nique is the use of fantasy. Patients might be in-
structed to daydream about positive memories or
situations that might distract them from present
anxiety. The use of fantasy is based on the premise
that it is impossible to maintain two simultaneous
cognitions or images, i.e. if one is focused on a relax-
ing image, it is not possible to focus on a negative,
anxiety-provoking one at the same time.
The final management option is the judicious use
of psychotropic medication. The goal is to decrease
the anticipatory anxiety of claustrophobia as well as
to minimize fear during the procedure itself. In the
inpatient setting, a rapid onset, relatively long-act-
ing benzodiazepine such as diazepam 2 to 10 mg by
mouth given approximately 30 to 60 minutes prior
to the procedure might be indicated. For the outpa-
tient, who would be commuting, a short-acting
benzodiazepine such as lorazepam 0. 5-1.0 mg or ox-
azepam 10-20 mg, by mouth 30 to 60 minutes before
the procedure, should be of help. Those patients who
are ambulatory should be cautioned concerning
sedation and psychomotor impairment and when-
ever possible, instructed to have someone to escort
them. Benzodiazepines are particularly useful for
the psychic (central) and anticipatory components
of anxiety. For those who have significant somatic
(peripheral) anxiety, a beta-blocker such as
propranolol, given orally 20 to 40 mg one hour prior
to the procedure, is suggested to decrease the ex-
cessive peripheral autonomic activity. The usual
contraindications to beta-blocker usage should be
observed, including a history of heart block and
bradycardia, bronchial asthma, and congestive
heart failure.
SUMMARY
The efficacy and safety of MRI has led to its in-
creased use as a diagnostic tool. As such, the ca-
pacity to ensure patient safety and comfort is criti-
cal. The specific psychiatric experience of claus-
trophobia appears to occur with greater frequency
during the MRI procedure than originally was be-
lieved. It is hoped that through a broader under-
standing of the phenomenology, etiology, and treat-
ment of this dysphoric reaction, the referring phy-
sicians, radiologists, and technicians will be better
able to manage their patients. ■
REFERENCES
1. National Institutes of Health Consensus Develop-
ment: Conference on Magnetic Resonance Imaging.
Bethesda, MD, 1987.
2. NY State Department of Health: New York State
Demonstration Project on Magnetic Resonance Imaging.
1987.
3. Brennan SC, Redd WH, Jacobsen PB, et al.: Anxiety
and panic during magnetic resonance scans. Lancet 2:512,
1986.
4. Quirk ME, Letendre AJ, Ciottone RA, et al.: Anxiety
in patients undergoing MR imaging. Radiology
170:463-466, 1989.
5. Fishbain DA, Goldberg M, Labbe E, et al.: Long-
term claustrophobia following magnetic resonance imag-
ing. Am J Psychiatry 145:1038-1039, 1988.
6. Campbell RJ: Psychiatric Dictionary. New York,
NY, Oxford University Press, 1989.
7. Hollander E, Liebowitz MR, Gorman JM: Anxiety
disorders, in Talbott JA, Hales RE, Yudofsky SC, The
American Psychiatric Press Textbook of Psychiatry,
Washington, DC, Am Psychiatric Press, Inc. 1988.
8. Seligman ME: Phobias and preparedness. Behau
Ther 2:307-320, 1971.
9. Liebowitz MR, Fyer AJ, Gorman JM, et al.: Lactate
provocation of panic attacks: Biochemical and behavioral
findings. Arch Gen Psychiatry 41:764-770, 1984.
10. Pavlov IP: Conditioned Reflexes in an Investigation
of Psychological Activity of the Cerebral Cortex. NY, New
York, 1960."
11. Freud S: Inhibitions, symptoms and anxiety, in,
Strachey J, The Standard Edition of the Complete Works
of Sigmund Freud. London, Hogarth Press, 1961.
12. Ellis JH, Dallas CS, Russell RJ: Communication
device for patients undergoing nuclear magnetic reso-
nance imaging. Radiology 149:855, 1983.
13. Hricak H, Amparo EG: Body MRI: Alleviation of
claustrophobia by prone positioning. Radiology 152:819,
1984.
14. Klonoff EA, Janato JW, Kaufman B: The use of
systematic desensitization to overcome resistance to
magnetic resonance imaging (MRI) scanning. J Behav
Ther Exp Psychiatry 17:189-192, 1986.
482
NEW JERSEY MEDICINE
Cancer in
Inguinal Hernias
JAMES W. KNECHT, MD
Cancer in inguinal hernias is rare. The author reports the first case of
thymoma metastatic to an inguinal hernia sac (saccular) and the 13th case
of colon cancer in an inguinal hernia (intrasaccular); both cases presented
clinically as incarcerated hernias.
It is unusual to find cancer in an inguinal
hernia. When found, it often is intrasaccular
(tumors derived from organs contained within
the sac). Saccular tumors (tumors involving the
hernia sac itself) are less common. I report on two
new cases: one case is an intrasaccular colon cancer
in a sliding left inguinal hernia presenting with in-
carceration (only 12 cancers of this type have been
previously reported) and one case of cancer that is
saccular (the first reported case of a thymoma
metastatic to an inguinal hernia sac).
CASE REPORT 1
A 95-year-old male was admitted with an ir-
reducible large left scrotal hernia, weight loss, and
change in bowel habits. He had an asymptomatic
Dr. Knecht is affiliated with the Department of Surgery,
Jersey Shore Medical Center, Neptune. This manuscript
was submitted in October 1989, and accepted in January
1990. Requests for reprints may be addressed to Dr.
Knecht, Jersey Shore Medical Center, 1945 State High-
way 33, Neptune, NJ 07753.
large left inguinal hernia for years. The colonoscopist
reported finding a cancer at the level of 30 cm and
a barium enema revealed the tumor to be in the
scrotal hernia (Figure 1). At operation, a sigmoid
tumor was in the hernia sac; it could not be reduced
through the internal ring. The proximal sigmoid
colon and mesentery, however, could be pulled out
through the enlarged internal inguinal ring. The
sigmoid colon was resected and the inguinal hernia
repaired through the hernia incision. The patient
made an uneventful recovery.
CASE REPORT 2
A 29-year-old male had a history of a sudden onset
of a swollen, painful, tender, right groin lump of
several days’ duration. He had a past history of
multiple thoracotomies, radiation, and chemother-
apy for malignant thymoma. He reported no change
in bowel habits or difficulty in eating. On physical
examination, an incarcerated right inguinal hernia
was found. An x-ray obstruction series was unre-
markable. A chest x-ray, although abnormal in ap-
VOL. 87— NUMBER 6 JUNE 1990
485
Figure 1. Barium enema showing constricting lesion in sigmoid colon in an
inguinal hernia.
pearance due to his previous resections, was un-
changed from previous films. At operation, the
hernia sac was adherent to the cord structures, and
when opened, contained fluid and two metastatic
thymoma tumor nodules (Figures 2 and 3). There
was a small communication between the sac and the
peritoneal cavity. An abdominal computed tomog-
raphy scan obtained postoperatively was normal.
COMMENTS
Inguinal hernia sacs can contain almost any struc-
ture in the abdomen, yet tumors rarely are found.
The first reported case of a primary hernia sac tumor
was by Araud in 1749.' Since that time, very few
additional cases have been reported. In 1954, Fieber
and Wolstenholme reviewed the world literature and
found only sporadic case reports." These included
carcinoma of the appendix, 3 fibrosarcomas, fibroma
of the mesentery, 2 mesotheliomas, carcinoma in a
bladder diverticulum, carcinoma of the bladder, 2
liposarcomas, and 2 colon carcinomas. Five years
later, Yoell reported that of 800 surgically excised
hernia sacs, only 3 hernia sacs were found to contain
tumors, an incidence of less than 0.4 percent.1 The
tumors included 1 colon cancer, 1 suspected prostate
cancer metastasis, and 1 metastatic cystadenocar-
cinoma of the ovary. In a 1980 review of world litera-
ture, Roslyn found only 23 primary hernia sac
tumors.4 In 1983, Kanzer and Rosenberg reported
finding an implant of hypernephroma in a hernia
sac/ Primary hernia sac tumors are classified ac-
cording to a system developed by Lejars into in-
trasaccular (an organ with tumor in a hernia sac) or
saccular (tumor involving the sac itself).6 Of the 23
cases of primary hernia sac tumors reviewed by
Roslyn, 16 tumors were found to be intrasaccular,
while 7 tumors were saccular. In his 1987 paper,
Pappas reviewed the literature and found only 11
previous cases of colonic cancer in an inguinal
hernia/ He reported the 12th case, and my case was
the next reported case.
In reviewing the literature on the less common
saccular tumors, I could find no previously reported
cases of thymoma metastatic to an inguinal hernia
sac.
Both cases reported in this paper presented
clinically as incarcerated hernias. Only one case was
confirmed to be incarcerated at operation (case 1).
A fluid-filled sac with metastatic thymoma tumor
nodules was found in the other case. The colonic
cancer reported by Pappas et al. also was com-
plicated by strangulation and perforation. One of the
486
NEW JERSEY MEDICINE
Figure 2. Low-power magnification of thymoma tumor
nodule with hernia sac wall.
two cases reported by Sriham and Nichols had an
incarcerated right inguinal hernia associated with a
colon cancer.8 Fieber and Wolstenholme comment
that a diagnostic feature in the majority of cases of
Figure 3. High-power magnification of thymoma from case
report 2, shown in Figure 2.
tumors in hernia sacs is the irreducibility of the
contents. They suggest that incarceration of a long-
standing hernia should alert the physician to the
possibility of a tumor. ■
REFERENCES
1. Araud G: Traite des hernias on Descentes. Paris Le
Mercier 2:3, 1749.
2. Fieber S, Wolstenholme J: Primary tumors in in-
guinal hernia sacs. Arch Surg 71:254-256, 1955.
3. Yoell JH: Surprises in hernia sacs, diagnosis of
tumors by microscopic examination. Calif Med 91:146-
148, 1959.
4. Roslyn JJ, Stabile BE, Rangenath C: Cancer in in-
guinal and femoral hernias. Am Surg 46:358-362, 1980.
5. Kanzer B, Rosenberg RF: Unusual contents in in-
guinal hernia sacs. NY State J Med 83:1055-1056, 1983.
6. Lejars J: Neoplasmes herniaires et periherniaires.
Gaz Hosp 62:801, 1889.
7. Pappas D, Romeu J, Pradyuman D, Subietas A:
Colonic carcinoma in an inguinal hernia sac. Case report
and review of the literature. Mount Sinai Med 54:162-164,
1987.
8. Sriham K, Nichols R: Colon carcinoma in inguinal
hernia. IL Med J 169:165-166, 1986.
VOL. 87— NUMBER 6 JUNE 1990
487
Meanwhile, he continues to
maintain rigid control on doctors’ fees.
The providers of medical services are
being discouraged economically and
those who need these services are
getting less of them.
We just want to make sure you
know where the squeeze is coming
from. Remember, you can do some-
thing about it. Cali or write your
congressman today.
Your County Medical Society and
The Medical Society
of New Jersey
2 PRINCESS RD„ LAWRENCEVILLE, NJ 08648
Uncle Sam is cutting back
on Medicare services he’ll pay for.
488
NEW JERSEY MEDICINE
Marketing
the Technologist
in the Physician Office Laboratory
KATHLEEN L. VOLDISH, CLA (ASCP)
The informed and conscientious physician who hires a certified technologist
can be prepared for the transitions that future state and federal regulations
bring to a private physician laboratory.
The number of physicians’ office laboratories
(POLs) is rapidly increasing. In-office test-
ing began as a few simple tests, such as
urinalysis, hematocrit, and glucose levels. Today,
the large POLs are very similar to small hospital
laboratories. In response to the testing performed in
POLs, the market for in-office in vitro products has
experienced a 26 percent compound annual growth
between 1984 and 1987. In 1989, this retail market
for in-office in vitro products grew to approximately
$750 million.1 In the past few years, laboratory
equipment manufacturers have entered the private
office marketplace at an aggressive pace. Where do
certified laboratory personnel fit into this picture?
The physician selects a system after considering in-
formation supplied by the manufacturer. The
statistics provided by the manufacturers are based
on the results the system produces when tests are
Ms. Voldish is a registered technologist and laboratory
manager. She is the New Jersey state advisor for the
Associate Member Section and a member of the Com-
mittee on Physician Office Laboratories, American So-
ciety of Clinical Pathologists. Questions for this column
can be addressed to Ms. Voldish, 1150 Concord Drive,
Haddonfield, NJ 08033.
performed in a hospital-like setting by trained lab-
oratory personnel. Little information, if any, is
provided concerning the accuracy and precision the
system will produce when operated by an office staff
with little or no formal laboratory training.23 Since
this type of objective evaluation not always is avail-
able, the physician is left to assume the system will
give reliable results regardless of the operator’s train-
ing or skill.
A study of technical performance and the training
and experience of staff4 compared laboratory test
results obtained on identical systems by noncertified
office workers (including nurses) and medical tech-
nologists certified by the American Society of
Clinical Pathologists. The test result accuracy scores
obtained by laboratories employing only certified
medical technologists was 95 percent (standard de-
viation: 4 percent) compared to 75 percent (standard
deviation: 30 percent) by laboratories employing
only noncertified medical technologists. Research
conducted by the Idaho Bureau of Laboratories re-
vealed other notable statistics.5 For example, ac-
ceptable quality control programs and records were
kept in 70 percent of office laboratories supervised
by medical technologists and in only 26 percent of
VOL. 87— NUMBER 6 JUNE 1990
489
office laboratories supervised by nurses. The study
also noted that most office staff workers had little
or no understanding of the concept of quality con-
trol. Maintenance logs on equipment were kept by
79 percent of technologist-supervised laboratories
compared to 33 percent of those supervised by
nurses. The variability of results was three to five
times greater in laboratories not employing certified
medical technologists. These studies concluded that
formal technical education and certification assure
more accurate results and that the quality produced
by the system often results more from the system
operator, not necessarily from the sophistication of
the equipment.
Establishing an office laboratory is a new aspect
of medical practice for most physicians. Medical
schools emphasize interpretation and application of
laboratory tests, not methodology.1 2 3 4 * The office practi-
tioner takes on the added responsibilities of labora-
tory director, including periodical review of all
aspects of the laboratory. The advantages of having
an office laboratory are numerous: convenience for
both the patient and physician, rapid turn-around
time resulting in more rapid treatment, and in-
creased revenue. These advantages quickly can be-
come insignificant if the laboratory test results are
inaccurate. The physician can be held professionally
responsible if incorrect test results adversely affect
patient outcomes.6 Manufacturers of office labora-
tory equipment may lead physicians to believe that
a two- to eight-hour training session will produce the
same accuracy of test results from a nontechnically
trained staff member as from a trained professional.
This assumption on the part of the physician may
compromise the quality of office testing. The phy-
sician who is willing to invest time and money to
select proper laboratory equipment also should take
the time to select the proper operator for that equip-
ment. The apparent ease of operating many exam-
ples of laboratory equipment can be dangerously
misleading. For most instruments, pushing a button
does not insure a correct result. Specimens must be
collected properly, identified, and stored. Stan-
dards, controls, and reagents that, require prep-
aration by the user must be precise. Proper calibra-
tion and routine maintenance must be performed.
Accurate records must be maintained; results must
be reported properly.7 Each step is critical. Medical
technologists have had formal didactic and clinical
training and have accumulated a wealth of technical
knowledge that can prove invaluable in an office
laboratory setting. The physician confidently can
delegate nearly all of the responsibilities of running
the laboratory to the technologist.2 The physician,
patient, and staff all benefit from the expertise
brought to the office setting by the technologist.
Only 30 percent of POLs now employ certified
medical technologists.8 Some states have defined
personnel standards for office laboratories; most
states have not.5,7 States that have few or no regu-
lations are approaching the adoption of such stan-
dards. The Health Care Financing Administration
plans nationwide proficiency testing under the
Clinical Laboratory Improvement Amendment
(CLIA) of 1988. POLs will have until July 1, 1991,
to meet personnel and inspection requirements of
CLIA. It is time the technologist gets marketed to
the private office as aggressively as the manufac-
turer markets laboratory equipment. Employment
in POLs offers technologists yet another setting in
which to offer their expertise. The POL atmosphere,
work schedule, and type of patient provide an
alternative to the technologist’s more traditional
work setting. The informed and conscientious phy-
sician who hires a certified technologist can be
prepared for the transitions that future state and
federal regulations will bring. A technologist will be
a great asset to the health care team in this new
setting just as he has been in the traditional setting.
ASSOCIATE MEMBER SECTION
COLA (Commission on Office Laboratory
Assessment) works extensively with the Department
of Health and Human Services to bring rational
regulations to office laboratories. They have applied
for “deemed status,” which if granted, means this
accreditation will be sufficient for an office labora-
tory to meet CLIA federal regulations. This is an
excellent path for physicians with POLs to take to
prepare for the future. More information about
COLA can be obtained from the POL Committee,
through the author. ■
REFERENCES
1. Georgen K: Revisiting physician office diagnostics.
Am Clin Lab 8:30-33, 1989.
2. Belsey R, Baer DM, Sewell D: Laboratory test
analysis near the patient. JAMA 255:775-786, 1986.
3. Belsey R, Vandenbark M, Goitein RK, Baer DM:
Evaluation of a laboratory system intended for use in a
physician’s office. JAMA 258:357-360, 1987.
4. Lunz ME, Castleberry BM, James K, Stahl J: The
impact of the quality of laboratory staff on the accuracy
of laboratory results. JAMA 258:361-363, 1987.
5. Crawley R, Belsey R, Brock D, Baer DM: Regulation
of physicians’ office laboratories: The Idaho experience.
JAMA 255:374-382, 1986.
6. Belsey R, Greene M, Baer DM: Managing liability
risk in the office laboratory. JAMA 256:1338-1341, 1986.
7. Board of Trustees Report: Clinical laboratory tests
and standards. JAMA 255:373, 1986.
8. ASCP/CAP 1986 Spring Meeting, Physician Office
Laboratories.
490
NEW JERSEY MEDICINE
Contraceptive Use
for Planned Parenthood Patients
LEWIS E. SAVEL, MD
Three hundred consecutive new patients coming to Planned Parenthood
clinics were reviewed. Of these patients, 68.3 percent were not using con-
traception and 67.8 percent had never used contraception. Also, 35.1 percent
had experienced one or more pregnancies, and 52 percent had first coitus
before 16 years of age.
In an effort to evaluate the extent of apathy
about using contraception, we reviewed 300
new patients coming to two clinic sites of
Planned Parenthood-Essex County. We studied 150
patients from an urban clinic (Chubb Center, New-
ark); and 150 patients from a suburban clinic (Egner
Center, Verona).
Of the patients reviewed, 68.3 percent were not
using contraception and 67.8 percent had never used
contraception. In the group not using contraception,
35.1 percent had experienced one or more preg-
nancies (Table 1).
At the urban clinic, 89.3 percent of the new pa-
tients were not using contraception; 67.1 percent had
never used contraception; and 40.3 percent had ex-
perienced pregnancy. At the suburban clinic, 47.3
percent were not using contraception; 69 percent of
these patients had never used contraception; and
25.3 percent had experienced pregnancy (Table 1).
Dr. Savel is medical director, Planned Parenthood-Essex
County. This paper was submitted in December 1989,
and accepted in February 1990. Requests for reprints
may be addressed to Dr. Savel, 49 Fern Hill Road,
Springfield, NJ 07081.
Among the 25,712 patient visits at Planned
Parenthood-Essex County (1988), 6,000 were for
pregnancy testing. Thus, 23.3 percent of all the
clinic visits related to possible pregnancy.
There were 164 patients in the study who were 19
years of age or younger; this was 54.6 percent of the
total group studied. Among this teenage group, 78.6
percent were not using contraception and 83.7 per-
cent had never used contraception. Pregnancy had
been experienced by 22.5 percent of these young
patients (Table 2). In this teenage group at the
urban clinic, 93.3 percent were not using contracep-
tion; at the suburban clinic, 60.8 percent were not
using contraception (Table 2).
In the group of patients 20 years of age or older,
there were 133 patients (44.4 percent of the total).
In this group, 51.8 percent were not using contracep-
tion, and 47.8 percent had never used contraception.
Among the 20 years of age or older patients, 68
percent had experienced one or more pregnancies
(Table 3). The pregnancies in this group, using no
contraception, could be voluntary, but the 22.5 per-
cent pregnancy rate noted in the 19 years of age and
younger group, more likely was inadvertent.
VOL. 87— NUMBER 6 JUNE 1990
493
Table 1. General statistics.
Urban Center Suburban Center
(Chubb) (Egner) Total
Number
Percent
Number
Percent
Number
Percent
Charts Reviewed
150
150
300
No Contraception
134
89.3
71
47.3
205
68.3
No Contraception/
No Previous
Contraception
90
67.1
49
69.0
139
67.8
No Contraception
And Pregnancy
54
40.3
18
25.3
72
35.1
Table 2. Group 19 years of age or less.
Urban Center
(Chubb)
Suburban Center
(Egner)
Total
Number
Percent
Number
Percent
Number
Percent
19 years of age or younger
90
74
164
54.6
19 years of age or younger/
no contraception
84
93.3
45
60.8
129
78.6
19 years of age or younger/
no contraception/'
no previous
contraception
69
82.7
39
86.6
108
83.7
19 years of age or less
no contraception and
previous pregnancy
18
21.4
11
24.4
29
22.5
Table 3. Group 20 years of age or older.
Urban Center
(Chubb)
Suburban Center
(Egner)
Total
Number
Percent
Number
Percent
Number
Percent
20 years of age or older
57
76
133
44.4
20 years of age or older/
no contraception
42
73.7
27
35.5
69
51.8
20 years of age or older/
no contraception
no previous contraception
18
42.8
15
55.5
33
47.8
20 years of age or older/
no contraception and
pregnancy
33
78.6
14
51.8
47
68.0
The age of the first coitus (Table 4) was before 16
years of age in 52 percent of the patients at the urban
center, and in 22 percent of the patients at the
suburban center. But the first coitus occurred at 17
years of age or older in 27.3 percent of the patients
at the urban center and in 56.6 percent of the pa-
tients in the suburban center.
DISCUSSION
From these statistics, it is apparent that a signifi-
cant number of patients coming to Planned Parent-
hood-Essex County clinics are not using contracep-
tion and more than half of these patients (67.8 per-
cent) had never used contraception. This highlights
the need for sex education to achieve the dictum,
“No woman should ever be pregnant unless she
wants to be.” The failure to use contraception
(78.6 percent) is a serious problem. The pregnancy
rate of 22.5 percent presents a social problem.
A startling revelation is the fact that in the 20
years of age and older group, 47.8 percent had never
used contraception. This occurred despite the wide-
spread attempts to educate women, starting at rela-
tively early ages. Our approach to teaching con-
494
NEW JERSEY MEDICINE
Table 4. Age of first coitus.
Years of Age
12
or
Less 13 14 15 16 17 18 19 20 Over 20
Urban Center 10 5 14 49 31 18 8 5 3 7
Suburban Center 1 6 9 18 31 40 24 11 6 4
15 years of age or less
Urban Center 10 5 14 49 Total 78 (52%)
Suburban Center 1 6 9 18 Total 34 (22%)
17 years of age or over
Urban Center
Suburban Center
traception and controlling pregnancy is flawed, and
must be corrected.
The population served in our urban center differs
significantly from the population seen in our
suburban center. The incidence of pregnancy,
without contraception, seems to vary significantly.
Of interest is the fact that 89.3 percent of new pa-
tients coming into the urban center were not using
contraception compared to 47.3 percent at the
suburban clinic, yet 67.1 percent at the urban center
and 69 percent at the suburban clinic had not used
contraception previously. Thus, suburban patients
finally had begun to use contraception (47.3 percent
not using now) whereas urban patients predominate-
ly still were not using contraception (89.3 percent).
The occurrence of first coitus in 52 percent of the
patients before 16 years of age at the urban center
compared to 22 percent at the suburban center cor-
relates with the rate of “no contraception” 93.3 per-
cent at the urban center and 60.8 percent at the
suburban clinic. Patients, who became sexually ac-
tive at an earlier age, were less likely to use con-
traception. The problem is manifestly more pressing
in the urban population than in the suburban popu-
lation where the first coitus occurs at 17 years of age
or older in 56.6 percent.
The need for improvement in sex education is
apparent. The deficit to be made up applies equally
to different population compositions, but it patently
is more urgent in the urban population. The need
to inform and to obtain compliance is imperative to
reduce a 22.5 percent pregnancy rate among women
19 years of age or younger. Pregnancy in this group
is particularly undesirable for its personal, social,
and community impact.
Realistically, much must be done to change the
sexual practices of women to avoid sexually trans-
mitted diseases and to obtain better control of child-
bearing. The goal of having each woman aware and
18 8 5 3 7
Total— 41 (27.3)
40 24 11 6 4
Total— 85 (56.6)
striving for personal control of her own childbearing
is desired. Sexual and contraceptive education of
teenagers must include discussions of abstinence,
but a broader educational approach is vital. A
woman who exposes herself to the “hazards of preg-
nancy” should have available the instruction and
choice of the method to control reproduction.
Teenagers should be encouraged to develop their
individual personalities so that self-confidence can
be achieved, enabling them to resist peer pressure.
Relationships that they establish should not depend
initially or primarily on sex. The informed patient
will be able to make an intelligent decision as to
when she will become pregnant or how she can con-
trol her fertility. This can be accomplished only with
increased efforts by schools, planned parenthood
groups, advisors, and parents.
SUMMARY
The study of 300 consecutive new patients coming
to the clinics of Planned Parenthood-Essex County
revealed the magnitude of the group not using con-
traception, 68 percent. Over 20 percent in the 19
years of age or less group had experienced pregnancy.
In the 20 years of age or older group, 68 percent
experienced pregnancy, some being intentional.
The statistics suggest that the problem of “no
contraception” is somewhat more acute among
urban patients (89.3 percent) than among suburban
patients (47.2 percent). Moreover, urban patients
experienced more pregnancies (40.3 percent) com-
pared to suburban patients (25.3 percent). The
earlier age of first coitus (before 16 years of age) in
the urban clinic related to the high incidence of “no
contraception” (93.3 percent in teenagers) and a
higher pregnancy rate.
Much is to be done to educate and guide women
of all ages and social groups to assist them in con-
trolling their own reproduction. ■
VOL. 87— NUMBER 6 JUNE 1990
495
A Successful
Partnership
STEPHANIE LICHTMAN, MPA
JOSEPH GORRELL, JD
Physicians considering partnership agreements should follow a well-de-
signed plan for recruitment, interviewing, and negotiation. This process can
ensure future success of the partnership, and prevent legal difficulties.
Physicians with established, successful prac-
tices often reach a point in their careers at
which they consider bringing a new physi-
cian into their practice. The reasons vary and may
include a desire to expand a practice, a means of
insuring financial security by providing a mecha-
nism for buy-out at retirement, a desire for pro-
fessional companionship, and the provision of stable
coverage that, can enable the physician to spend
Ms. Lichtman is owner of a health care consulting firm,
and Mr. Gorrell is a member of the law firm of Brach,
Eichler, Rosenberg, Silver, Bernstein, Hammer & Glad-
stone, PA. This article was submitted in November 1989,
and accepted in January 1 990. Requests for reprints may
be addressed to Ms. Lichtman, The Planning Group, 98
Cypress Neck Road, Lincroft, NJ 07738.
more time outside his practice. Physicians consider-
ing bringing a physician into their practice should
properly evaluate whether a partnership is the right
arrangement for them.
THE FIRST STEPS
The initial questions are: Can the practice
financially absorb a new associate? Does the practice
have a volume of patients to support an associate?
Is there potential for expansion of the practice?
Having decided that enlarging the practice will be
beneficial, the first consideration is finding an ap-
propriate candidate. Various ways to locate your
new associate include: contacting professional as-
sociations and residency programs; advertising in
professional journals; retaining professional recruit-
496
NEW JERSEY MEDICINE
ers; and word of mouth. Consideration also may be
given to discussions with colleagues or competitors
interested in merging practices.
Once candidates have been contacted, and after
receiving the candidates’ curriculum vitae, the pro-
cess is twofold: interview the candidate, preferably
at your office, and bring the candidate to hospitals
at which you practice. Secondly, when you identify
a candidate in whom you are interested, it often is
beneficial to invite him for a social visit; this oc-
casion can help you gain insight into the candidate
and begin to build a relationship.
Initial Questions
• Can the practice financially
absorb a new associate?
• Does the practice have a volume
of patients to support an associate?
• Is there potential for expansion
of the practice?
Once you have selected a candidate, references
should be contacted. These should include not only
the names provided by the applicant, but also any
directors of the candidate’s training programs.
NEGOTIATIONS
During the interview process, it is useful to for-
mulate issues important to you in developing a con-
tract. You will want to consider starting salary,
fringe benefit packages, and appropriate buy-in and
buy-out arrangements should you decide to bring the
physician into your practice as a partner.
Finding an attorney who is experienced in nego-
tiating medical partnerships is an important step.
Names can be obtained from colleagues who have
been through the process, a local medical society,
and the local bar association. At the same time, you
will want to meet with your accountant to discuss
the financial status of the practice and then ask the
attorney and accountant to work together.
While it is not necessary for the attorney to nego-
tiate the basic terms with the candidate’s attorney,
it is useful to obtain guidance as to what terms
should be discussed with the candidate. These issues
will include: compensation, including fringe ben-
efits; direction and control of the practice during the
initial years; an appropriate period of time for mak-
ing the decision if and when the candidate will be
eligible for partnership; the inclusion of a pro-
ductivity clause; whether a restrictive covenant will
be included should the candidate separate from the
practice; the on-call and coverage responsibilities of
the new associate; and the potential for expansion
of the practice.
Probably the one thing the candidate will want to
raise after compensation will be whether partnership
is on the horizon. Assuming that partnership is to
be considered, you will have to decide whether basic
partnership issues are decided at the outset or
whether these will be deferred until you have de-
cided to bring the associate in as a partner. Partner-
ship issues include:
1. What will be the business form of the practice,
i.e. partnership or professional corporation?
2. Where will the principal office be and will ad-
ditional offices be established?
3. How much initial capital will be needed and in
what proportion will it be contributed?
4. Will all partners be required to devote all their
professional services exclusively to the partnership?
5. Will there be a buy-in to the practice, and if
so, on what terms?
6. What are the partnership expenses, including
legal fees, accountant’s fees, medical equipment and
supplies, office equipment, pension contributions,
and health, disability, life, and malpractice in-
surance?
7. Will the senior member of the practice be the
managing partner, and if so, for how long?
8. What events can trigger a termination of one
of the members from the practice?
9. What method will be established for paying the
debts of the practice and distributing the remaining
assets if you dissolve the practice?
10. Will either physician be restricted geographi-
cally in establishing a new practice?
11. Will the senior physician be compensated, for
example, in the case of retirement?
These issues are but examples of the variety of
factors that should be considered when a new physi-
cian is brought into a practice. Complete discussion
of these issues with the candidate prior to entering
your practice can obviate later misunderstandings
and avoid future legal disputes.
SUMMARY
Once you have decided that your practice would
benefit from and could support a partner, you should
carefully select a candidate using a well-thought-out
interview process. Careful review of all partnership
issues in advance of any contract can help obviate
later misunderstandings and avoid future legal dis-
putes. Advanced planning can help guarantee that
your future partner will be an asset, not a liability,
to your practice. ■
VOL. 87— NUMBER 6 JUNE 1990
497
RADIOLOGY ROUNDS
Cystic Right
Upper Quadrant Mass
JAMES H. JACOBY, MD
Radiograph of a cystic right upper quadrant mass is presented with differen-
tial discussion of pancreatic and biliary cystic lesions.
Our patient is a 39-year-old white female
with a one-month history of epigastric and
right upper quadrant pain related to fried
and fatty foods. Her initial attack lasted approx-
imately eight hours and was characterized by con-
tinuous pain and nausea. Physical examination and
laboratory data workup were normal.
The demonstration of mass effect upon the
duodenal loop on an upper gastrointestinal series
prompted performance of a computed tomography
(CT) scan (Figure 1).
DISCUSSION
The CT scan demonstrated a well-defined,
homogeneous, 5 cm low density mass occupying the
head of the pancreas. Cystic neoplasms of the pan-
Dr. Jacoby, editor of this column, is acting chairman,
Department of Diagnostic Radiology and Nuclear Medi-
cine, Cooper Hospital, Camden, and clinical assistant
professor of radiology, UMDNJ-Robert Wood Johnson
Medical School. Requests for reprints may be addressed
to Dr. Jacoby, Cooper Hospital/University Medical
Center, One Cooper Plaza, Camden, NJ 08103.
Figure 1. Computed tomography scan demonstrating a 5 cm
smoothly marginated low-density mass located in the region of
the head of the pancreas.
creas are relatively uncommon, and account for only
10 percent of all cystic pancreatic masses. Micro-
cystic adenomas (serous cyst adenomas) occur pri-
marily in the elderly and may vary in size from 1
to 12 cm. These tumors have virtually no malignant
potential. Although these tumors frequently involve
the head of the pancreas, the microcystic consisten-
cy of this mass frequently presents as a solid-appear-
498
NEW JERSEY MEDICINE
RADIOLOGY ROUNDS
ing tumor on CT examination and an echogenic or
hypoechoic mass on ultrasound examination.
Macrocystic adenomas (mucinous cyst adenomas),
in contradistinction, do occur in the younger age
population, with a 6:1 female preponderance. Unlike
the microcystic variety, these tumors contain mucin
and have a malignant potential. While they may be
large, frequently they involve the tail or body of the
pancreas and often are multiloculated with thick
septa. At times, these tumors may be difficult to
distinguish from pseudocysts of the pancreas.
Pseudocysts of the pancreas generally are as-
sociated with other signs of pancreatitis, including
pancreatic effusions or diffuse enlargement of the
pancreas. Frequently, they are not as well
marginated as this mass and they often contain
internal debris. The diagnosis of pancreatitis gener-
ally is established clinically; this patient had no
signs or symptoms of pancreatitis.
An endoscopic retrograde cholangiopancreato-
gram (ERCP) (Figure 2) showed a focal common
duct dilatation disproportionately large compared to
the degree of dilatation of the common hepatic duct
and normal intrahepatic radicles. The mass, there-
fore, represents a choledochal cyst. This condition
affects a preponderance of females (81 percent) and
is found predominantly in children and young
adults. The classic triad of abdominal pain, jaun-
dice, and a right upper quadrant abdominal mass
is seen in only 38 percent of patients. Three main
varieties of choledochal cyst have been described.
Alonso-Lej type A is the most common, representing
localized dilatation of the common duct, as in this
case. The least common, type C, is a cystic dilata-
tion of the intraduodenal or intrahepatic portion of
the duct, a choledochocele. Type B, even more rare,
represents a congenital diverticulum connected by
a stalk to the common duct, the hepatic ducts, or
the gallbladder. Coexisting cholangitis, progressive
biliary obstruction, eventual hepatic cirrhosis and
Figure 2. Radiograph from endoscopic retrograde cholangio-
pancreatogram (ERCP) demonstrating normal pancreatic duct
and dilated common bile duct.
portal hypertension, stone formation, and spon-
taneous rupture, as well as cholangiocarcinoma are
all potential complications.
This patient had excision of her choledochal cyst
and gallbladder in continuity and a choledochoje-
junostomy, Roux-en-Y, was performed. Post-
operatively, the patient has done well with complete
disappearance of pain and food intolerance. ■
Radiology Rounds and its companion, Radiology Review, will
be a new feature for NEW JERSEY MEDICINE. The format will
include a radiograph and clinical issue, as well as a brief
discussion and diagnosis; selected references will be noted.
Contributions to this column are welcome.
REFERENCES
1. Araki T, Itai Y, Tasaka A: CT of choledochal cyst.
AJR 135:729-734, 1980.
2. Sarris G, Tsang D: Choledochocele: Case report,
literature review, and a proposed classification. Surgery
105:408-414, 1989.
3. Lee -JK, Sagel SS, Stanley RJ: Computed Tomo-
graphy with MRI Correlation, 2nd Edition. New York,
NY, Raven Press, 1989, pp. 560-577.
VOL. 87— NUMBER 6 JUNE 1990
499
Golden Merit Award
Recipients
At ceremonies held on May 7, 1990, during the 224th Annual Meeting of the
Medical Society of New Jersey, at the Sands Hotel, Casino & Country Club,
Atlantic City, the following physicians received MSNJ’s Golden Merit Award,
indicating they held the degree of Doctor of Medicine for 50 years.
Atlantic County
Maurice Bear Gordon, MD .... Hahnemann 1940
Josiah Calvin McCracken, Jr, MD
Pennsylvania 1940
John Millerd Naame, MD Georgetown 1940
Bergen County
Herbert Henry Eccleston, MD Buffalo 1940
Matthew Feldman, MD Tulane 1940
Harold F. Hailman, MD Illinois 1940
Peter George Hunziker, MD Columbia 1940
John F. W. King, MD Jefferson 1940
Robert August Kritzler, MD Cornell 1940
Bernard Ross, MD Glasgow 1940
Carl Eliot Rothschild, MD Maryland 1940
Joseph Silber, MD Lithuania 1940
William Eric Williams, MD Cornell 1940
Ruth Zuckerman, MD
New York University 1940
Burlington County
William Pinkerton Mulford, MD .. Virginia 1940
Alan Murray Schaeffer, MD Jefferson 1940
Camden County
Robert Arthur Cooper, MD Temple 1940
Elmer Louis Grimes, MD Tufts 1940
Magdalena G. Jurado, MD .. Santo Tomas 1940
William Donald Kimler, MD Temple 1940
Chauncey Kay McGeorge, MD Temple 1940
William J. Snape, MD Jefferson 1940
Cumberland County
Sherman Garrison, MD Pennsylvania 1940
Essex County
Marvin C. Becker, MD
New York University 1940
Anthony Richard Bombardieri, MD
Bologna 1940
Peter John Cetta, MD Hahnemann 1940
Stephen Dmytriw, MD Georgetown 1940
Frederick W. Douglas, MD Howard 1940
Robert Eugene Erler, MD Columbia 1940
John Ralph Evans, Jr, MD Vermont 1940
Raymond Harold Gehl, MD Michigan 1940
Bernard German, MD Harvard 1940
500
NEW JERSEY MEDICINE
Mehmet Firuzi Goklen, MD Istanbul 1940
Albert Edwin Holderith, MD . Georgetown 1940
Joseph Israel, MD Edinburgh 1940
Robert Bremer Marin, MD .... Hahnemann 1940
J. Tufton Mason, Jr, MD Columbia 1940
Samuel Harry Pomerantz, MD
Edinburgh 1940
Bernard Sager, MD Glasgow 1940
Anthony Michael Sarno, MD* ... St. Louis 1940
Alan Leslie Smith, MD Columbia 1940
Charles Hodges Smith, MD Temple 1940
Harold Marston Somberg, MD
Long Island 1940
Spurgeon Sparks, Jr, MD Meharry 1940
Irving Leslie Sperling, MD
New York University 1940
Donald Elwood Stokes, MD Cornell 1940
John A. Strazza, Jr, MD Cornell 1940
Clifford James Tichenor, MD
New York Medical 1940
John Robert Tobey, MD Pennsylvania 1940
Gloucester County
Thomas B. Mervine, MD Jefferson 1940
! Hudson County
Morris B. Feldman, MD Tennessee 1940
Herman I. Frank, MD Cornell 1940
1 Sidney Katz, MD Scotland 1940
Louis Albert Monica, MD St. Louis 1940
Philip Joseph Russillo, MD Maryland 1940
H. Albert Scala, MD Rome 1940
Edward E. Shapiro, MD Virginia 1940
Mercer County
Florante C. Bocobo, MD Philippines 1940
Samuel Arnold Guttman, MD Cornell 1940
Middlesex County
Robert William Powers, MD Columbia 1940
John Francis Scalera, MD Jefferson 1940
Albert Aaron Schwartz, MD Dalhousie 1940
Murray Wagman, MD Toronto 1940
James Sabey Winn, MD
George Washington 1940
Monmouth County
Milton E. Haut, MD Glasgow 1940
Evelyn P. Ivey, MD Johns Hopkins 1940
William J. Koch, MD Georgetown 1940
Robert George McCurdy, MD Temple 1940
Norman Nathanson, MD Louisville 1940
Morris County
Albert Abraham, MD
New York University 1940
Samuel Justin Arnold, MD St. Louis 1940
L. Earle Arnow, MD Minnesota 1940
Augustus Lynn Baker, Jr, MD
New York University 1940
Joseph F. Zigarelli, MD Yale 1940
Ocean County
Sidney Alpert, MD Vermont 1940
Pascal Friscia, MD Bologna 1940
Passaic County
Herbert R. Farber, MD Virginia 1940
Leo Feld, MD Glasgow 1940
John R. Fenwick, MD Georgetown 1940
Alex Hochman, MD Dalhousie 1940
Richard Elmer Lang, MD Hahnemann 1940
A. Gerard Peters, MD
New York University 1940
James August Rogers, MD .... Hahnemann 1940
Louis L. Salerno, MD Loyola 1940
Aaron Schwinger, MD Cincinnati 1940
Somerset County
Godfrey S. Hyer, MD Lausanne 1940
Bernard Marcus, MD Rush 1940
Harold Nathaniel Wender, MD
Edinburgh 1940
Union County
Fidel Antonio Aguirre, MD Havana 1940
Harold Richard Berger, MD
New York University 1940
John Paul Cannis, MD
New York University 1940
Arnold Newman Constad, MD ... St. Louis 1940
Aaron J. Kaycoff, MD
New York University 1940
Joseph George Palin, MD Glasgow 1940
Max Barr Rosenblatt, MD Louisville 1940
James A. Wolff, MD
New York University 1940
*Posthumously
VOL. 87— NUMBER 6 JUNE 1990
501
NOTEBOOK
■■TRUSTEES’ REPORT*
A meeting of the Board of
Trustees was held on April 8, 1990,
at the executive offices in Law-
renceville. Detailed minutes are on
file with the secretary of your coun-
ty society. A summary of signifi-
cant actions follows:
Committee on Long-Range Plan-
ning and Development . . .
Adopted the proposed goals and
objectives (professionalism; unity;
organizational structure; quest for
quality; communication and pub-
lic relations; and legislation) for-
mulated by the Committee, and
commended the Committee for its
excellent report.
Report of the President . . .
(1) Pam Formica: Candidate for
AMA Board of Trustees . . .
Complimented Dr. Formica on her
campaign efforts.
(2) Speaker and Vice-Speaker
. . . Appointed Dr. Karl T.
Franzoni as speaker of the House
of Delegates and Dr. Edward A.
Schauer as vice-speaker of the
House of Delegates.
(3) Candidate Nominating
Speeches . . . Noted that can-
didates will have the option to
present a statement of intent and
purpose if they so desire before the
House at the election session.
(4) Representation on the Board
of Trustees . . . Referred to the
Committee on Revision of Con-
stitution and Bylaws for consider-
ation the matter of the develop-
ment of a formal mechanism for
the inclusion of medical specialty
society and hospital medical staff
section representatives on the
Board of Trustees.
(5) New Jersey State Medical
Underwriters, Inc. . . . Noted the
following information: the Office of
the Chairman, a group that guides
the insurance company between
meetings of the Board of Directors,
is involved with the search for the
new president; election of mem-
bers of the Board of Directors was
deferred until the final meeting of
the MSNJ Board of Trustees on
May 5, 1990; and an ad hoc com-
mittee is being formed to serve as
liaison between MSNJ and the in-
surance company, and Dr. Hirsch
wil be chairman of the committee.
(6) Academy of Medicine of New
Jersey Annual Dinner . . . Noted
the date of the annual dinner is
May 30, 1990.
(7) Special Dues Category . . .
Referred to the Committee on
Long-Range Planning and De-
velopment the issue of a special
dues category for physicians in
full-time academic positions, and
noted that the chairman of the
Committee on Finance and Budget
will be invited to participate in the
discussion.
Report of Executive Director . . .
(1) MSNJ Paid Membership . . .
Noted that paid membership as of
March 1990 is 6,508 with 3,441
members also belonging to the
American Medical Association.
(2) Financial Statements . . .
Reviewed and approved MSNJ
financial statements for the period
ending February 28, 1990.
(3) April 1990 Medicare Changes
. . . Noted that the AMA analysis
of all the changes (a 5-year tran-
sition to a new payment schedule
based on an RBRVS beginning in
1992; a 3-year transition to new
balance billing limits beginning in
1991; and the establishment of
Medicare volume performance
standards beginning this year) in
the Omnibus Reconciliation Act of
1989 will be provided to the Board.
(4) State Board of Medical
Examiners (SBME) . . . Noted
the following items: SBME has
petitioned the State Board of
Pharmacy to require physicians to
file schedule III and IV prescrip-
tions separately so SBME in-
vestigators can become more effi-
cient in monitoring physician
prescriptions; and a proposed regu-
lation allowing physicians to del-
egate specified tasks to physician
assistants in certain settings.
(5) Litigation . . . Noted the fol-
lowing items: the case of SBME
versus Sinha is awaiting a decision
by the Appellate Division; the case
of MSNJ versus the State Board of
Physical Therapy is awaiting a de-
cision of the Appellate Court; and
a decision on the MSNJ versus
Merin case will be rendered within
30 to 60 days following argument,
scheduled for early June.
(6) Legislation . . . Noted the fol-
lowing items: optometric drug use,
A-743 (authorize optometrists to
diagnose disease and prescribe
drugs), moved out of committee;
commissioner of health, S-642
(eliminate requirement of a medi-
cal license for the commissioner of
health), emerged from committee
though MSNJ has been actively
opposed to the bill; declaration of
death, S-1208 (two tests for death
would be required, scientific and
religious), passed the Senate; and
living will, S- 121 1 (would bring
about an operative living will
statute), passed the Senate.
502
NEW JERSEY MEDICINE
Committee on Finance and
Budget . . . Approved the follow-
ing recommendations:
That the budget for the fiscal year be-
ginning June 1, 1990, and ending May
31, 1991, in the amount of $4,286,000
with $2,590,000 to be raised through
member assessments be adopted.
That the 1991 assessment be set at
$350 per regular dues-paying member.
(No change from prior year.)
That the 1991 assessment be set at $60
per member for affiliate members (no
longer practicing in New Jersey). (No
change from prior year.)
That the 1991 assessment for associate
members (interns/residents nonli-
censed in New Jersey) and licensed
residents, provided the individual is in
a residency program entered upon
within a reasonable time after his/her
graduation for medical school, be set at
$25. (No change from prior year.)
That the 1991 assessment be set at $10
per student for medical students. (No
change from prior year.)
Committee on Membership Ser-
vices . . . Postponed consideration
of the following recommendation
until DocShop, Inc., is a function-
ing enterprise:
That the Board of Trustees endorse
DocShop, Inc., a warehouse club sell-
ing medical and dental products to
professionals at a discount.
Council on Public Relations . . .
Approved the following two rec-
ommendations:
That the Board of Trustees urge coun-
ty medical societies to establish health
care programs for senior citizens utiliz-
ing physician speakers.
That the Board of Trustees approve
the formation of a committee to engage
in membership recruitment and reten-
tion, with the Council on Public Rela-
tions acting in a supportive capacity.
Correspondence . . . Received let-
ters from Charles A. Janousek, ex-
ecutive director, SBME, in
response to MSNJ’s letter indicat-
ing that neither UMDNJ nor its
affiliated hospitals should be in-
volved in a pilot project regarding
physician assistants; and from
James S. Todd, MD, acting ex-
ecutive vice-president of the AMA,
expressing assurances of the
AMA’s commitment to the im-
paired physicians program. □
■HUMDNJ NOTES
James C. Wallace, assistant
chancellor for fiscal affairs of the
New Jersey Department of Higher
Education, has been appointed as-
sociate vice-president for resource
management at UMDNJ. Mr.
Wallace will be responsible for the
University budget, facilities plan-
ning, and capital financing. His
valuable experience in finance and
planning, plus his extensive knowl-
edge of the state system, will be
especially helpful as we allocate
limited resources while main-
taining the excellence of our
academic, research, and health
care programs. Mr. Wallace will
succeed Howard Buxbaum, who
has been named executive director
for administration and planning at
UMDNJ-Robert Wood Johnson
Medical School, Piscataway.
UMDNJ is seeking as many as
1,300 volunteers for the largest na-
tionwide study of how heterosexual
partners acquire the AIDS virus
through sexual contact. The five-
year study, coordinated by
UMDNJ-New Jersey Medical
School, has received a $13.8
million award from the National
Institute of Allergy and Infectious
Diseases of the National Institutes
of Health. The volunteers are
being recruited primarily from
Newark, Paterson, and Jersey City
because these three cities have
been identified as having com-
paratively high numbers of het-
erosexuals infected with the
human immunodeficiency virus
(HIV) that causes AIDS. New Jer-
sey is unique among states with
large numbers of AIDS cases be-
cause 65 percent of the individuals
infected with AIDS are hetero-
sexual.
Four hospitals will participate
with UMDNJ in the study —
UMDNJ-University Hospital and
Saint Michael’s Medical Center,
both in Newark; Jersey City
Medical Center; and Saint
Joseph’s Hospital and Medical
Center, Paterson.
Surgical treatment for epilepsy
patients is being initiated at the
Comprehensive Epilepsy Center of
UMDNJ-Robert Wood Johnson
Medical Center, New Brunswick.
With the addition of the surgical
component, the two-year-old Cen-
ter can provide full-service diag-
nosis and treatment for epileptics.
Approximately 50 patients a year
will be able to receive epileptic sur-
gery at the UMDNJ Center. A two-
bed monitoring unit has been es-
tablished at the Robert Wood
Johnson University Hospital for
the Center’s epileptic surgery com-
ponent. All diagnostic tests, along
with surgical procedures, will be
performed at the hospital, the core
teaching hospital of the medical
school.
An ophthalmologist at UMDNJ-
Robert Wood Johnson Medical
School has developed a surgical
technique to allow patients with
facial paralysis to open and close
their eyes. Dr. David Soli, clinical
professor of surgery and ophthal-
mology at the medical school’s
Camden campus, developed a
surgical technique to treat this
problem that involves two steps.
First, a small piece of cartilage,
taken from the back of the ear, is
placed into the inside of the lower
eyelid for support. He then inserts
a tiny gold weight (about half the
size of a dime) to the upper eyelid.
The weight forces the eyelid down.
The cartilage improves eyelid
function, enabling the patient to
open and close the eyelids. The
most important factor is finding
the right size weight — one heavy
enough to close the eye but light
enough to allow it to re-open.
Dr. Soil measures the weight by
testing different sizes on the
outside of the eyelid when the pa-
tient is sitting. The patient then is
sedated while the weight is in-
stalled. An alternative to the gold
VOL. 87— NUMBER 6 JUNE 1990
503
weight is to attach a spring to the
inside of the upper eyelid.
Minor plastic surgery may be
needed in some cases to tighten the
skin around the eye to ensure com-
plete closure and comfort. Also, it
may be necessary to insert a lubri-
cating protective ointment in the
eye at night for patients who still
have trouble producing enough
tears. All patients had improve-
ments in the movement of their
eyelids and no serious side effects.
□ Stanley S. Bergen, Jr, MD
■BMSNJ AUXILIARY ■■■
At the Annual Meeting of the
Medical Society of New Jersey
Auxiliary, Jane Lorber of Union
County was installed as the or-
ganization’s 64th president. She is
the wife of Richard Lorber, MD, a
urologist and medical director of
clinical research at Schering
Plough.
Mrs. Lorber was born and raised
in Harrisburg, Pennsylvania, and
is a graduate of the Harrisburg
Hospital School of Nursing. After
completing her training, Jane
worked as a surgical nurse at the
hospital where she met Dr. Lorber,
a surgical intern. They were mar-
ried in 1974 and have two children,
Jennifer, 14; and Brian, 11.
In 1977, shortly after the Lorbers
moved to New Jersey, Jane joined
the Union County Medical Aux-
iliary. She immersed herself in
Auxiliary activities and projects.
Her enthusiasm, energy, and or-
ganizational abilities were quickly
recognized and she was appointed
chairman of various committees
and eventually elected to the of-
fices of second- and first vice-presi-
dent, and president. Then moving
on to the state level, Jane served
as AMA-ERF chairman, recording
secretary, vice-president, and
president-elect.
In addition to her Auxiliary
work, Jane is active in the com-
munity. She is a member of the
Scotch Plains Board of Adjust-
ments and the Republican Munici-
pal Committee. She also has
served in leadership positions in
the PTA, the YMCA, and the Girl
Scouts. As a member of the Junior
Women’s Club, she chaired “Jaws
For Life,” receiving national ac-
claim. In 1982, Jane was selected
as one of the “Outstanding Women
of America.” □ Marion H. Geib
■■PLACEMENT FILEHH
These physicians are looking for
opportunities in New Jersey:
GENERAL PRACTICE
Randi Silverbrook, DO, 3024 Wistar
Ct., Bensalem, PA 19020. College of
Osteopathic Medicine 1985. Partner-
ship or group. July 1990.
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Also, internal medicine. Available.
INTERNAL MEDICINE
Leonid Belopolsky, MD, 955 Chan-
ticleer Dr., Cherry Hill, NJ 08003.
Moscow 1961. Board certified (ANES).
Also, general practice. Available.
David D. Gross, MD, 1045 Liberty St.,
Apt. 1, Trenton, NJ 08611. St.
George’s University (Grenada) 1987.
Board eligible. Available August 1990.
Marc Kesselhaut, MD, 1 Rustic Ridge,
C16, Little Falls, NJ 07424. St.
George’s University 1986. Board
eligible. Solo or partnership in Mercer,
Somerset, Burlington, Hunterdon, or
Middlesex counties. Available Sep-
tember 1990.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner-
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital-based. Available
July 1990.
PATHOLOGY
Judith Vople, MD, 106 Orlando Blvd.,
Toms River, NJ 08757. UMDNJ 1985.
Board eligible. Group or hospital-
based. Available July 1990.
PHYSICAL MEDICINE
Robert B. Thorne, MD, 112 Woodside
Ave., Trenton, NJ 08618. Rutgers 1980.
Board certified. Part time or full time.
Available.
Jane Lorber, the 64th president of the MSNJ Auxiliary.
504
NEW JERSEY MEDICINE
CONTINUING EDUCATION
INFECTIOUS DISEASE
July
18 Clinical Management of HIV
Infection
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ and NJDOH)
27 Clinical Management of HIV
Infection
12 Noon-1 P.M. — Medical Center
of Ocean County, Point Pleasant
(AMNJ and NJDOH)
August
21 Clinical Management of HIV
Infection
7:30-8:30 A.M. — Mercer Medical
Center, Trenton
(AMNJ and NJDOH)
21 AIDS Training and Resource
Program
8-9 A.M. — Wallkill Valley
Hospital and Health Center,
Sussex
(AMNJ and NJDOH)
MEDICINE
July
3 Grand Rounds
10 8:30-10 A.M. — Elizabeth General
17 Medical Center, Elizabeth
24 (Elizabeth General Medical
31 Center)
6 Cardiovascular Effects of
rhIGF-I in Normal Subjects
2-3 P.M. — Ciba-Geigy, Summit
(Ciba-Geigy)
10 Occupational Lead Poisoning in
New Jersey
12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(NJDOH)
11 Anti-Hypertensive Therapy:
Benefits Beyond Blood Pressure
Control
1-2 P.M. — Deborah Heart and
Lung Center, Browns Mills
(Deborah Heart and Lang Center)
11 Diagnostic Uses of MRI
1-2:30 P.M. — RCHP, Route 1,
New Brunswick
(RCHP)
24 Medical Aspects of Rabies
12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(NJDOH)
26 Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
8- 9 P.M. — Freehold Area Hospital,
Freehold
(AMNJ)
August
7 Grand Rounds
14 8:30-10 A.M. — Elizabeth General
21 Medical Center, Elizabeth
28 (Elizabeth General Medical
Center)
7 Topics in Public Health
12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(NJDOH and AMNJ)
16 New Treatment Modalities and
Implications for the Future of
Diabetes
7:30-8:30 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
ONCOLOGY
July
12 Tumor Board
9- 10 A.M. — Irvington General
Hospital, Irvington
(Irvington General Hospital)
13 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley Hospital Center)
August
9 Tumor Board
9-10 A.M. — Irvington General
Hospital, Irvington
(Irvington General Hospital)
10 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley
Hospital Center)
PSYCHIATRY
July
3 Psychiatry Grand Rounds
10 8:30-10 A.M. — Elizabeth General
17 Medical Center, Elizabeth
24 (Elizabeth General Medical
31 Center)
5 Treatment Approaches To
Obsessive Behavior
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
12 Light at the End of the Tunnel
12 Noon-1 P.M.— Carrier
Foundation, Belle Mead
( Carrier Foundation)
19 The Violent Patient
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
25 Treatment of Borderline
Personality Disorder
1:30-2:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(Trenton Psychiatric Hospital)
August
2 NMR: Application to Affective
Illness and Lithium
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
7 Psychiatry Grand Rounds
14 8:30-10 A.M. — Elizabeth General
21 Medical Center, Elizabeth
28 (Elizabeth General Medical
Center)
9 Foods, Fats, and Fraud Diets
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
16 Food and Fitness Habits
i2 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
30 Brain Imaging and the
Electroconvulsive Patient
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
SURGERY AND ITS SPECIALTIES
July
26 High-Risk Surgery
11:30 A.M. -12:30 P.M. —United
Hospitals Medical Center,
Newark
(AMNJ)
VOL. 87— NUMBER 6 JUNE 1990
507
IN MEMORIAM
Paul Aptekar. A pediatrician
involved in community projects for
many years, Paul Aptekar, MD,
died at the age of 61. Born in the
Bronx, New York, Dr. Aptekar re-
ceived his medical degree from the
University of Mexico, Mexico City,
in 1957 and his license to practice
medicine in Mexico the same year.
Dr. Aptekar served his internship
and his residency in pediatrics at
Kings County Hospital, New York.
In 1960, he received his New Jersey
medical license. Dr. Aptekar had a
private pediatrics practice in
Lakewood and was affiliated with
Kimball Medical Center, Lake-
wood. In addition, Dr. Aptekar was
a member of our Ocean County
component.
Neil Castaldo. A longstanding
member of 50 years of the Medical
Society of New Jersey, Neil
Castaldo, MD, died on March 27,
1990, at the age of 81. Dr. Castaldo
was born in Bayonne, on Septem-
ber 23, 1908, and earned his medi-
cal degree from St. Louis Univer-
sity School of Medicine, St. Louis,
in 1933. He served his internship at
Bayonne Hospital, and his resi-
dency at Jersey City Medical
Center, and received his New Jer-
sey license in 1934. Dr. Castaldo
was a surgeon and a general practi-
tioner and the medical inspector
for the Cranford Board of Educa-
tion for many years. He also was
affiliated with Rahway Hospital,
and with St. Elizabeth Hospital,
Elizabeth. Active in school health
examinations, Dr. Castaldo served
as chairman of the special commit-
tee on school health for the Medi-
cal Society of New Jersey and pub-
lished an article, “Toward Better
School Health Examinations” in
NEW JERSEY MEDICINE. Dr.
Castaldo served in the United
States Army Medical Corps during
World War II from 1942 to 1943
and attained the rank of captain.
He was stationed at the Walter
Reed Army Medical Center, Wash-
ington, DC. Dr. Castaldo was a
member of the American Medical
Association and of our Union
County component, and a fellow of
the International College of Sur-
geons.
Italo J. Falcone. Word has been
received of the death of Italo John
Falcone, MD, on March 21, 1990,
in Italy, where he spent his latter
years. Dr. Falcone, born on March
6, 1923, in Newark, received his
medical degree from LIniversity of
Milano, Italy. In 1950, Dr. Falcone
received his New Jersey license. He
served an internship at St. Peter’s
Medical Center, New Brunswick.
Dr. Falcone had a general surgical
practice in New Brunswick and
was affiliated with two New Bruns-
wick hospitals, St. Peter’s Medical
Center and Robert Wood Johnson
University Hospital. Dr. Falcone
was a member of our Middlesex
County component and of the Ital-
ian Medical Society.
Melvin W. Lipowitz. We have
received word of the death of
Melvin W. Lipowitz, MD, on April
11, 1990, at the untimely age of 54.
An internist, Dr. Lipowitz earned
his medical degree from George-
town University School of Medi-
cine, Washington, DC, in 1964 and
received both his New Jersey and
New York licenses the following
year. He served an internship at
Newark Beth Israel Medical Cen-
ter, Newark. Born in Newark on
September 9, 1935, Dr. Lipowitz
had his private practice there and
was affiliated with several hospi-
tals: Rahway Hospital, Newark
Beth Israel Medical Center, and
John F. Kennedy Medical Center.
He was a member of the American
Medical Association, of our Essex
County component, and of the
New York Academy of Sciences.
Robert W. Powers. Born on
September 1, 1914, in Rome, New
York, Robert William Powers,
MD, died on January 10, 1990, at
the age of 75. A retired general sur-
geon, Dr. Powers received his
medical degree from Columbia
LIniversity College of Physicians &
Surgeons, New York. After serving
in the LTnited States Army Medical
Corps during World War II from
1942 to 1945 as captain, Dr. Powers
obtained his New Jersey license in
1949. Dr. Powers had a private
surgical practice in New Bruns-
wick, and was affiliated with two
New Brunswick hospitals: St.
Peter’s Medical Center, and Rob-
ert Wood Johnson University Hos-
pital. He was a member of our
Middlesex County component, of
the American Medical Association,
and of the Academy of Medicine of
New Jersey.
Send member obituaries to:
Membership Department, MSNJ
Two Princess Road, Lawrenceville, NJ 08648
508
NEW JERSEY MEDICINE
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
vision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statement accompany-
ing material offered to NEW JER-
SEY MEDICINE must contain the
following language and must be
signed by all authors.
“In consideration of NEW JER-
SEY MEDICINE taking action in
reviewing and editing my sub-
mission, the author(s) undersigned
hereby transfers, assigns, or other-
wise conveys all copyright own-
ership to the Medical Society of
New Jersey, in the event that such
work is published in NEW JER-
SEY MEDICINE.
Specifications. Submit two
manuscripts that must be type-
written and double-spaced on 8V>"
by 11" paper. Statistical methods
should be identified.
Authors are asked to seek clar-
ity, accuracy, and originality; at-
tention to details of grammar,
spelling, and typing are important.
The title page should include the
full name, degrees, and affiliations
of all authors, and the name and
address of the author to whom re-
print requests and correspondence
should be sent.
The author should submit a 30-
word abstract.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission must be
submitted.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote
with the first use of the generic
name. Proprietary names of de-
vices should be indicated by the
registration symbol — 11 .
References should not exceed 35
citations except in review articles,
and should be cited consecutively
by numbers in parentheses at the
end of the sentence. The reference
list should be typewritten and
double-spaced on separate 8V2" by
11" sheets in numerical order. The
style of NEW JERSEY MEDI-
CINE for references is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
viewers and the authors will be
permitted, but authors will be in-
formed of the reviewers’ com-
ments. Galley proofs will be sub-
mitted to the author for correction.
Reprint Orders. Reprints may be
ordered after the author is notified
that the article has been selected
for a specific issue. A check for the
cost of reprints must accompany
that order.
Communications. All com-
munications should be sent to the
editor, NEW JERSEY MEDI-
CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
VOL. 87— NUMBER 6 JUNE 1990
509
EMERGENCY ROOM
PHYSICIANS
Our community hospital emergency room is look-
ing for board eligible or board certified Physicians
to assist in seeking an average of 26,000 patients
yearly.
We need a Physician with pediatric training who
is willing to see adult patients as well as children.
Plus a Physician to see adults only.
We offer double coverage from 1 1 :00 AM to 1 1 .00
PM and a competitive salary.
Interested individuals please contact Dr. Angelo
Scotti, (201) 739-5902.
BAYSHORE
COMMUNITY
HOSPITAL
727 No. Beers Street
Holmdel, NJ 07733
Equal Opportunity Employer
BUYING OR SELLING A PRACTICE?
It is one of the largest and most important business
transactions you will ever make. You can handle it your-
self, spend a great deal of time and energy trying to
make such a sale work, and risk not getting a fair
market price. Or, you can turn to EPSTEIN PRACTICE
BROKERAGE, INC. Our brokerage service includes
consultation, appraisal, screening, and negotiation of
terms. Additionally, we will arrange for institutional
financing.
EPSTEIN PRACTICE BROKERAGE, INC.
16 West Palisade Avenue
Englewood, New Jersey 07631
(201) 568-4933
mWine opportunities
PERSONNEL
Pages 510, 511, 513,
514, 515
REAL ESTATE
Pages 510, 512, 513,
514, 515
NEW MEDICAL BUILDING
EAST BRUNSWICK, NEW JERSEY
ORTHOPEDIC SURGEON
3,400 sq. ft. prestigious two-story building, off
Greater New York City. Expanding orthopedic
Hwy. 19, in East Brunswick, opposite large shop-
surgery practice seeks another partner. Large
ping mall.
hospital with ER and orthopedic floor, assured
Available for rent immediately to one or many
referral base, excellent medical and management
tenants.
Excellent Terms
support. Salary, benefits, partnership.
Call owner
Call Walter R. Smith, PhD
(212) 824-1560, 1569 (9-5 pm)
(800) 221-4762 or (212) 599-6200
(201) 567-5694 (after 6 pm)
Physician
PHYSICIAN OPENINGS
Nonprofit, ambulatory, community health center
NEUROLOGIST
seeks a pediatrician and a Medical Director, fam-
ily practice or internal medicine specialties
Ancora Psychiatric Hospital has an opening for a
preferred. Applicants must be board eligible or
consulting neurologist (Board Certified or Board
board certified, with a commitment to serving
eligible) to direct our Neurology clinic. Ancora
underprivileged communities.
Psychiatric Hospital is a 600 bed State facility
Send resume to: Personnel Department
located midway between Philadelphia and Atlan-
Charter Oaks Terrace/Rice
tic City. For more information please contact
Heights Center
Harold J. Kobb, M.D., Chief of Medicine, (609)
81 Overlook Terrace
567-7302. ANCORA PSYCHIATRIC HOSPITAL,
Hartford, Connecticut 06106
Hammonton, NJ 08037. EOE
equal opportunity employer
NEW JERSEY MEDICINE
510
PRO VERSUS MSNJ
On May 21, 1990, the federal district court issued the following
rulings in the PRO case:
1. PRO is entitled to communicate directly with doctors
to initially notify them a potential problem exists in
furtherance of PROs contractual and statutory
obligations .
2. As a matter of law, there is no reason why a
doctor's response must be done personally for PRO to
consider it. Likewise, there is no reason why a
response made by counsel who has been retained to
represent a doctor during the review process is not
binding on the doctor.
3. PRO'S motion to prohibit the Medical Society of New
Jersey from deposing Mr. Madden and Mr. Margolies is
denied .
As the prevailing party in this case, MSNJ now is applying for
attorney's fees.
MEDICAL WASTE REGISTRATION/REFUNDS
Refunds are due to physicians by July 2, 1990. The state mailed
refund applications to doctors for clarification of refund
entitlement status; only 60 percent responded. The remaining
40 percent will be recontacted; refunds will not be processed
unless physicians provide the requesting data to the Department
of Environmental Protection. The money will revert to the state
unless properly claimed. Annual report requests will be mailed
out shortly as well as the 1990 renewals.
PHYSICIAN ASSISTANTS
The State Board of Medical Examiners has proposed a rule to
authorize the use of physician assistants in New Jersey. The
Society is opposed to that action and has retained former
federal Judge Herbert S. Stern to represent the membership.
A public hearing will be held on August 15, 1990, in Trenton.
Physicians opposed to the State Board rule should plan to attend
and should send comments in opposition to Michael Grossman, DO,
President, New Jersey State Board of Medical Examiners, 26 West
State Street, Trenton, NJ 08625.
TODD NAMED AMA CHIEF
James S. Todd, MD, of Ridgewood, a former chairman of the Board
of Trustees of MSNJ and NJSMU, was named executive
vice-president of the AMA on June 20, 1990. Replacing retiring
James Sammons, MD, Dr. Todd is expected to preside over a
restructuring and redirection of the AMA.
MSNJ
NEWSLETTER
1990 CODES FOR Medical Administration Publications announced the release of the newly
MEDICARE revised 1990 HCPCS Level II National Codes. A supplement to CPT,
the codes in this manual are used to report supplies and injections to
Medicare. This publication is fully indexed and set up like CPT for ease
of use. Symbols identify new, revised, and deleted codes. An introduction
explaining how and when to use these codes is provided for your refer-
ence. And the spiral binding keeps the book open, making it even easier
to use. If you report supplies or injections to Medicare or Medicaid, you
need these codes. Copies of this 228-page publication may be obtained
from Medical Administration Publications (MAP), 671 Executive Drive,
Willowbrook, IL 60521. The cost of the book is $28 plus $3.50 for shipping
and handling.
AMA HEADQUARTERS The staff of the AMA will be moving into leased space in a new head-
MQyg quarters building in Chicago in August. The new address is 515 North
State Street, Chicago, IL 60610. The general office phone number will
be 312/464-5000.
HANSEN’S DISEASE The Regional Hansen’s Disease Program provides medical services to
PROGRAM Hansen’s disease patients throughout the United States. In order to
achieve the program’s goal of providing care in each patient’s communi-
ty, a nationwide network of over 900 physicians has been developed.
Network physicians represent numerous medical specialties and have
varied backgrounds, but share a common interest in managing Hansen’s
disease patients. There are approximately 6,000 patients with Hansen’s
disease living in the United States today. The Regional Hansen’s Disease
Program has identified 3,700 of these patients as currently being under
treatment. Physicians who choose to utilize the program’s resources can
obtain medications, patient education materials, insensitive limb screen-
ing materials, and clinical literature at no charge. Any physician with
an interest in managing Hansen’s disease patients can be placed on the
program’s referral list. Interested physicians should contact Mr. Larry
Pfeifer, clinical coordinator, at 1/800/642-2477.
NJ HEALTH According to a report by Citizens Action, New Jersey spends more per
CARE SPENDING person on health care than any nation, other than the United States.
The report was based on information from 1982 to 1986 provided by the
Health Care Financing Administration and the Organization for Eco-
nomic Cooperation and Development of the United Nations. According
to the data, New Jersey spends $1,643 per person per year, compared
to $2,051 for the United States and $1,515 per person for Canada, the
number 2 ranked nation in per capita health spending.
HEALTH The Senate recently approved a bill that allows for future nonphysician
COMMISSIONER commissi°ners of health. The bill would allow for this as long as one
of the deputy commissioners is a physician. By allowing for nonphysi-
cians, a wider range of qualified individuals may apply for the position.
The new bill (S-642) does require that the commissioner be trained and
experienced, and hold an advanced degree in the public health field.
VOL. 87— NUMBER 7 JULY 1990
525
Additionally, the candidate must have five years of full-time adminis-
trative or executive experience with a public health agency and some
experience in community health facilities planning. The bill must be
passed by the Assembly.
CHAPTER 83 Hospitals now are required to submit an updated profile to the Hospital
HOSPITAL PROFILES Rate-Setting Commission before it will take action on any hospital’s
schedule of rates. The updated profile statistics and other relevant
financial information must be through 1989 and should be submitted
in writing no later than one week prior to the scheduled Commission
meeting date.
REVIEW DRG New Jersey Hospital Association (NJHA) President Louis P. Scibetta
PAYMENT SYSTEM ^as announced the creation of a task force, comprised of 16 New Jersey
hospital executives and trustees, to review the current health care regu-
latory scene. The task force will develop a document that could be used
as part of a state master plan on how hospital rates are set, how hospitals
operate in New Jersey, and who pays for the health care costs of the
poor. The task force will be named the “President’s Task Force on
Regulatory Reform,” will report to the NJHA Board of Trustees, and
present its recommendations to Governor Florio. The task force will
examine such items as New Jersey’s diagnosis related group hospital
payment system, the certificate of need system, rewarding hospitals for
efficient operations, encouraging the development of less costly outpa-
tient services, and assuring access to care regardless of ability to pay.
DEPARTMENT OF Commissioner Alan Gibbs’s first priority will be a review of the entire
HUMAN SERVICES operations of the Department of Human Services. The review will en-
compass the 23,000 employees of the Department, as well as services
provided to the one million clients of the Department. The Com-
missioner’s immediate focus will be on the 658-person central office.
HEALTH CARE On April 20, 1990, Governor Florio announced the appointment of an
STUDY 18-member health care commission to study the health care crisis in New
Jersey. The commission is comprised of six state cabinet members, two
legislators, and nine members of the public. The six cabinet members
include Human Services Commissioner Alan Gibbs, Health Com-
missioner Dr. Frances Dunston, Insurance Commissioner Samuel For-
tunato, Labor Commissioner Raymond Bramucci, Public Advocate
Wilfredo Caraballo, and Treasurer Douglas Berman. The two com-
mission members from the legislature are Senator Richard Codey (D-
Essex) and Assemblyman James McGreevy (D-Middlesex). Brenda
Bacon, head of the Governor’s Office of Planning and Management, will
chair the commission.
PHYSICIAN By a unanimous vote, the State Board of Medical Examiners approved
ASSISTANTS in principle a two-year pilot program allowing physician assistants to
work in teaching hospitals and state institutions. Physician assistants
also would serve as the first or second surgical assistant on minor
procedures. Physician assistants are trained and practice in the same
manner as military paramedics, and act much like hospital residents in
other states. New Jersey is the only state that does not allow the use
of physician assistants, which has been opposed in the past by physician
and nurse groups.
PHYSICIAN PAYMENT According to Health and Human Services Chief Louis Sullivan, MD,
INCREASE proposed Medicare physician payments will increase by only 9.9 percent
in 1991 due to budgetary constraints. HHS’s 9.9 percent increase
526
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
proposal to Congress on the Medicare Volume Performance Standard
(MVPS) includes an inflation increase of 3.6 percent, an enrollment
increase of 1.2 percent, and unquantified factors for an aging beneficiary
population, utilization changes, access difficulties, and new technology.
MVPS, a part of overall 1989 physician payment reform initiatives, is
intended to slow the rate of spending increase for physician services from
its current 12 percent annual trend. In addition to the overall expen-
diture target, HHS plans to limit growth of surgical and other physician
payments to 8.7 percent and 10.5 percent, respectively.
BOEHM
PORCELAIN
At her New Jersey studio, Helen F. Boehm (left) presents one of her
world-famous porcelains to Palma E. Formica, MD (right). Mrs. Boehm
donated the exquisite piece as a prize in a raffle held for Dr. Formica’s
election campaign. Dr. Formica is running for a position on the AMA
Board of Trustees.
MEDICAL Medical inflation rose 0.8 percent in March as compared to a 0.5 percent
INFLATION UP increase m the overall consumer price index, according to the Labor
Department. March price increases included a 1.1 percent increase in
hospital room rates and a 0.7 percent increase in outpatient fees. These
increases compared to respective February increases of 0.5 percent and
1.4 percent.
PHYSICIAN The Physician Payment Review Commission (PPRC) criticized the Ad-
PAYMENT REFORM ministration’s attempt to accelerate the Physician Payment Reform pro-
gram. Concerns were voiced by the PPRC that trying to implement the
program too quickly could throw the whole process of payment reform
out of kilter and would not provide a suitable time frame within which
to encourage private insurers to join with the government program.
DOCTORS LEAVING According to a study by the General Accounting Office, low salaries are
MILITARY driving physicians from military service into civilian life where they can
find the dollars to meet their needs. The demand for administrative
chores and the inability to always practice their specialty also added
to the reason some 2,000 out of 13,000 doctors left the service in 1988.
GAO urges Congress to increase the salaries of military physicians.
VOL. 87— NUMBER 7 JULY 1990
527
MSNJ NEWSLETTER
MALPRACTICE Arguing over whether medical malpractice costs increase the cost of
COSTS health care, the doctors and lawyers compiled the statistics. The
comptroller general of the General Accounting Office stated that from
1983 to 1985 the cost of medical malpractice insurance increased over
60 percent to approximately $1.3 billion. Dr. James S. Todd, acting
executive vice-president of the American Medical Association indicated
that because of the fear of claims and lawsuits, physicians are performing
more tests and procedures, and as a result, health care costs increased
by $19.3 billion in 1988. President of the Association of Trial Lawyers
of America, Russ Herman, noted that the cost of a malpractice lawsuit
was less than 1 percent of the total health care cost in 1987.
HOSPITAL
CLOSINGS
According to data compiled by the American Hospital Association, 65
hospitals closed during 1989 compared to 12 hospitals opening. Texas
experienced the highest number of closings with 13 during 1989, followed
by Colorado with 6 and Mississippi with 5. Seven of the 12 hospitals
that opened during 1989 were reopenings of hospitals that previously had
closed, while 16 of the facilities that closed in 1989 continue to offer
outpatient services. Rural hospital closings amounted to 44 of the 65
closings in 1989. The number of hospital closings was 85 in 1988 and
77 in 1987, while 508 hospitals closed during the decade.
OUTPATIENT
SURGERY
In a report to Senator Jay Rockefeller (D-WV), and Representative Peter
Stark (D-CA), the General Accounting Office (GAO) concluded that
Medicare can reduce overpayments for outpatient surgery by implement-
ing a prospective payment system now as opposed to waiting for
widescale reform. GAO has suggested deducting coinsurance from allow-
able costs rather than allowable charges, and not holding coinsurance
to 20 percent of allowable charges, as two alternatives for achieving
savings.
CLEAN AIR
BILL
Representative Robert Dole (R-KS) has introduced an amendment to
the revised clean air bill that will establish less stringent standards for
hospital incinerators than those required for municipal waste-burning
plants. The amendment will ensure that hospitals still can use on-site
incineration. The Senate’s original measure would have increased hospi-
tal incineration and maintenance costs by $412 million annually, or
$91,500 per hospital. The Senate bill passed on an 89-11 vote margin.
HOSPITAL
PRICES
Health Care Investment Analysts, an investment research firm, has
found that hospital competition increases costs and charges as hospitals
add services to attract physicians and patients. The study focused on
more than 2,000 hospitals in three markets: markets with one hospital,
markets with two or three hospitals, and markets with four or more
hospitals. Costs were 17 percent greater for hospitals in markets with
four or more facilities than markets with one hospital, while charges were
24 percent greater in markets with more than three hospitals compared
to those areas with only one hospital.
INSURANCE COMPANY
REQUESTS
It has become common for insurance companies to request additional
patient information beyond the completion of claim forms. The Board
of Trustees of the Medical Society of New Jersey believes that New
Jersey physicians are entitled to compensation for the time spent in
providing this information. You should notify the patient and the carrier
that the extra service will involve a charge, and that the written
authorization of the patient must be on file in your office before you
can proceed.
FINI
“There is no softer pillow than a clear conscience.”
528
NEW JERSEY MEDICINE
PROFESSIONAL
LIABILITY
PRACTICING MEDICINE A physician was properly convicted of delivering a controlled substance
WITHOUT A LICENSE and practicing medicine without a license, a Michigan appellate court
ruled. The physician was convicted of delivery of a controlled substance
for other than legitimate and professional therapeutic purposes on Janu-
ary 19, 1982. He was placed on probation and forbidden to hold a
controlled substance license during his probation. After his conviction,
he made arrangements with another physician to continue his practice
during his suspension.
The other physician had a DEA license and prescribed phentermine for
his diet control patients. On April 25, 1982, he delegated authority to
the office staff and the physician on probation to refill maintenance
prescriptions for patients who still were overweight but who had no
particular problems and who previously had been prescribed a mainte-
nance dose by a licensed physician. The written authorization was given
pursuant to state law.
A sheriff s narcotics officer and a police informant contacted two of the
physician’s longtime patients. They agreed to provide the money and
transportation to the physician’s office if the patients would refill their
prescriptions for diet pills and split the pills with the officer and the
informant. Neither patient knew that the informant and the officer were
associated with the sheriffs department in any way.
The physician refilled the prescriptions, and the patients gave the agreed
share to the officer. The pills were turned over to the police laboratory,
where they were identified as phentermine, a schedule IV controlled
substance.
After an appellate court ruled that the other physician could not as a
matter of law delegate his authority to the physician on probation, a
trial court convicted him on two counts of delivering controlled
substances and one count of practicing medicine without a license.
Affirming the stated decision, the appellate court said that the physician
was not the victim of entrapment. (Reprinted with permission from The
Citation, American Medical Association, Vol. 60, March 15, 1990)
HOSPITAL CAN SEEK
INDEMNITY FROM
RADIOLOGIST AND
CORPORATION
A settlement agreement between a patient and a radiologist did not
preclude a hospital’s claim for indemnification from the radiologist and
her radiological services corporation, a Louisiana appellate court ruled.
The patient sustained a back injury at work on January 10, 1978. He
was taken to a hospital and x-rayed. Since the hospital did not have
a resident radiologist, the x-rays were sent out to be read. A radiologist
read the x-rays, but failed to diagnose a fractured cervical vertebra. The
patient claimed that the failure of the radiologist to interpret the x-rays
properly contributed to development of paralysis.
During the course of litigation, a settlement was reached between the
patient, the radiologist, and her insurance company. After the radiologist
^OL. 87— NUMBER 7 JULY 1990
531
PROFESSIONAL LIABILITY
and her insurance company were dismissed from the action, the hospital
sought to add the radiologist, her insurance company, and her pro-
fessional corporation as third-party defendants. A trial court granted
summary judgment dismissing the third-party complaint, and the hospi-
tal appealed.
Reversing the trial court’s decision, the appellate court said that the
radiologist failed to establish that releasing her released her professional
corporation. The settlement agreement between the patient and the
radiologist did not preclude the hospital’s claim for indemnification from
the radiologist and her professional corporation, the court said. (Re-
printed with permission from The Citation, American Medical Associa-
tion, Vol. 60, April 1, 1990)
DOCUMENT Economic pressures may increase your risk for malpractice allegations
RESTRICTIONS BY of failure to diagnose and failure to refer. Physicians often ask how they
THIRD-PARTY PAYERS mi&ht prevent such allegations of negligence when the plan (with which
he contracts) inhibits the ability to order tests, restricts referrals, or
economically penalizes the physician for providing needed care. If you
see Medicare patients or belong to a PPO, IPA, or HMO, sooner or later
you may face this problem.
In the case of a bad outcome, who is held accountable for medical care
decisions — the plan or the physician? Our experience has shown that the
physician often bears the major burden of such claims in dollars, time,
and emotional distress. How can you guard against these allegations?
On a case-by-case basis, consider the following suggestions:
1. Write your recommendations, rationale, and consequences of
not following your recommendations to the plan administrator
with a copy to the patient.
2. Stand by your recommendation, communicating to the pa-
tient the importance of the proposed care and the perceived conse-
quences of not proceeding as recommended. Urge the patient to
obtain needed care even if such care will not be covered by a
medical plan.
3. Document in the patient’s chart, objectively and without
editorial comment, all efforts to convince the patient and the plan
administrator. If both refuse, use your best medical judgment to
either: proceed with care within the parameters allowed; or ter-
minate the physician-patient relationship if other providers are
available to accept transferred care within the guidelines of the
plan. Explain to the patient your concern that you cannot con-
tinue to provide care against your own best judgment.
(Reprinted with permission from Medical Legal Alert, January 1990,
published by Mutual Insurance Company of Arizona)
PROFESSIONAL James E. George, MD, JD, is director of the Department of Professional
LIABILITY Liability Control, Medical Society of New Jersey, and A. Ronald Rouse
is director of Special Projects, Medical Society of New Jersey.
Please address all comments and concerns to A. Ronald Rouse, Director
of Special Projects, Medical Society of New Jersey, Two Princess Road,
Lawrenceville, NJ 08648. Mr. Rouse also can be reached by calling
609/896-1766, at Medical Society of New Jersey headquarters in Law-
renceville.
532
NEW JERSEY MEDICINE
EDITOR’S
DESK
POTPOURRI Many of us have resisted utilizing the spate of technologic marvels
developed in recent years. Some of us are computer illiterate, put to
shame by our children and our grandchildren, despite the widespread
use of these devices in offices and in hospitals. (The problems associated
with down time — all too frequently — tend to perpetuate this illiteracy.)
Even programming a VCR seems beyond the capabilities of some, re-
gardless of the detail or simplicity of the manual supplied.
But many who are resistant to these gadgets have succumbed to simpler
instruments — cordless telephones and, especially, telephone answering
machines. Once used, we wonder, “How did we ever do without them?”
They are convenient and do prevent the loss of important messages. The
initial resistance to the employment of answering machines seems much
abated as their numbers have escalated. But the use of recorded solici-
tations still provokes involuntary banging down of the receiver. And we
do have glitches when rerecording messages.
In keeping with the proliferation of home and business answering ma-
chines, we also have noted the development of computerized telephone
answering in hospitals and other businesses: “If you know the extension
of the department you are calling, press X. If you do not, wait for an
operator.” And, where are those extension numbers — on a paper filed
away with other important documents or on a wallet-sized card with
digits so miniscule as to require a magnifying loupe? Could we not return
to the personal touch of an operator or be furnished with plasticized
cards containing numbers that do not strain these old tired eyes?
IN MEMORIAM: The annual meeting of the Physician Insurers Association of America
PETER SWEETLAND <PIAA> was dedicated to Peter Sweetland, late president of the New
Jersey State Medical Underwriters, Inc. and a founding father of the
Medical Inter-Insurance Exchange of New Jersey and PIAA. Many trib-
utes were given and it seems appropriate to publish the following one
from James S. Todd, MD: “How does one assimilate the loss not only
of a treasured friend, but a person who contributed so much to the
medical profession in his quiet, gentle way. Pete and I worked closely
together for over ten years, and never during that time did I see him
lose his patience, become discouraged, or disparage anyone or anything.
Even more remarkable, during that time was the development of a
unique relationship between those with whom he worked, and a unique
understanding of the needs of the profession he was serving so faithfully.
His ability to translate the complicated to the simple, the adverse to
the possible, and the doubters to the believers was phenomenal. Yet it
was Pete himself who was so extraordinary. He died as he lived, steadfast
to the task, never complaining, never willing to say enough, and by so
doing leaves a legacy toward which we should all aspire: devotion to
family, devotion to his work of excellence, and devotion to his friends.
We all, especially I, have lost one who not only was my teacher, but
one of the truest friends any person could have. Rest in peace, Pete, and
know you were loved.” So say we all. □
VOL. 87— NUMBER 7 JULY 1990
535
YOCON*
YOHIMBINE HCI
Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees .
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolaikylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine’s peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.
Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone
Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.
Indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.
Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications
Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.
Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.12 Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence,1’3 4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to % tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000's NDC
53159-001-10.
References:
1. A. Morales et al. , New England Journal of Medi-
cine: 1221 . November 12, 1981 .
2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed ., p. 176-188.
McMillan December Rev. 1/85.
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales etal . , The Journal of Urology 1 28:
45-47, 1982.
Rev. 1/85
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536
NEW JERSEY MEDICINE
BOOK
REVIEWS
CLINICAL
IMPLICATIONS OF
ABNORMAL DIGESTIVE
TRACT RADIOGRAPHS
David A. Morowitz, MD. Philadelphia, PA, Lea & Febiger, 1990. In this
book, Dr. Morowitz is limiting his discussions to the clinical implications
of abnormal digestive tract radiographs-barium studies, cholangiograms,
and plain films of the abdomen. There are no detailed discussions of
radioisotopic techniques, imaging studies such as sonography, com-
puterized abdominal tomography, or magnetic resonance imaging. In-
deed, there is not a single endoscopic picture.
Dr. Morowitz presents brief discussions, clinical vignettes appropriate
to the particular gastrointestinal problem illustrated by one to three
pertinent x-rays. His aim is “to serve the reader as a kind of tell me
now what I need to know survival kit.” There are no references. Un-
fortunately, the reader may need to know more about some of these
clinical problems. I feel a few key references would be an invaluable tool
to direct the reader in the right direction.
Although I found most of the discussions well written, neat, and thought-
ful, there were some suggestions I questioned. I feel that metronidazole
is a more appropriate alternative to oral vancomycin in the management
of pseudomembranous colitis than either trimethoprim-sulfamethox-
azole or corticosteroids.
The material presented should be familiar to experienced gastro-
enterologists and radiologists. However, those readers who are in the
process of developing diagnostic and clinical skills in gastroenterology
will find the format informative and practical. I recommend the book
to students and residents taking a gastrointestinal rotation. It also will
be useful to internists and family practitioners who see large numbers
of common digestive problems. □ Joel D. Levinson, MD
IRRITANT CONTACT
DERMATITIS
E.M. Jackson and R. Goldner (editors). This text fulfills a unique niche
in the collation of information associated with irritant contact
dermatitis. In a review of the literature, there is a plethora of information
and immunological research regarding allergic contact dermatitis. How-
ever, irritant contact dermatitis has been superficially investigated. This
text brings together the available literature into a single cohesive vol-
ume.
The text is divided into three parts: inflammation; exposure to irritants;
and diagnosis and testing for irritants. The first part, comprised of three
chapters, is an evaluation of the inflammatory response. The second
part, composed of four chapters, discusses exposure to irritants in the
occupational setting, in cosmetic and topical drug therapy, and in
plants. Finally, diagnosis of irritant contact dermatitis is developed in
three chapters on in vitro and in vivo clinical tests, and clinical tests
to identify compounds with the potential to cause irritation.
The textbook is recommended to complement the library of
dermatologists and allergists/immunologists interested in the study of
immunodermatology, and physicians involved in occupational medicine.
□ Leonard Bielory, MD
VOL. 87— NUMBER 7 JULY 1990
537
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538
NEW JERSEY MEDICINE
SPECIAL ISSUE
Lyme Disease
in New Jersey
The explosive growth in the number of reported cases
of Lyme disease in New Jersey is astonishing. There-
fore, it is imperative for all physicians to understand
how to prevent exposure and to recognize early signs of the
illness in order to develop appropriate treatment.
An interdisciplinary symposium on Lyme disease re-
cently was sponsored by UMDNJ-Robert Wood
Johnson Medical School, the New Jersey Veterinary
Medical Association, the New Jersey State Nurses Associa-
tion, and the New Jersey Health Officers Association. This
symposium was part of a new clinical prevention initiative
created by UMDNJ-Robert Wood Johnson Medical School
faculty. The initiative is designed to have a positive impact
on the preventive aspects of care provided by physicians
practicing in New Jersey.
In this special issue, we highlight the major papers from
the two-day conference on Lyme disease, to help our
readers explore the disease and to review and update
diagnostic and treatment protocols.
The audience at the two-day symposium listens attentively to the
presentations. Speakers include (top to bottom): Drs. Mary Swigar,
John Post, and Anita Curran. © A.J. Sundstrum
VOL. 87— NUMBER 7 JULY 1990
539
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NEW JERSEY MEDICINE
Lyme Disease:
Prevention and Control
ANITA S. CURRAN, MD, MPH
The author describes a public health education program directed at Lyme
disease prevention and control. This program, conducted from 1983 to 1989,
targeted three major segments of the community— the general public, health
care providers, and elected officials.
Research into the etiology and epidemiology
of Lyme disease has produced significant
results over the last decade. Much has been
earned, but there is much about the detection,
irevention, and control of this disease that still
ludes us. The sensitivity and specificity of readily
vailable laboratory tests still is less than would be
esired. Treatment is problematic and a safe and
ffective vaccine is years away.
The only reliable method of preventing Lyme dis-
ase is the prevention of tick bites; to date, there is
)r. Curran is assistant dean for clinical affairs and
irofessor of clinical environmental and community
ealth, UMDNJ-Robert Wood Johnson Medical School,
lequests for reprints may be addressed to Dr. Curran,
IMDNJ-Robert Wood Johnson Medical School, 1 Robert
Vood Johnson Place, CN 19, New Brunswick, NJ 08903.
no safe, effective, and practical method of large-
scale tick control. As a consequence, control of this
disease must be approached with an intense public
health education campaign.
This paper describes a campaign developed and
conducted by the Westchester County Health De-
partment during the years 1983 to 1989. Westchester
County, New York, is one of the areas most severely
impacted by Lyme disease in the northeastern Unit-
ed States. The first few cases were diagnosed in 1981.
The commissioner of health directed that a major
public health education campaign be developed to
alert the public and the health care practitioners to
this growing menace. To be successful, this cam-
paign had to be waged along several battlefronts
simultaneously: the community; health care pro-
fessionals; and elected officials. The messages had
IOL. 87— NUMBER 7 JULY 1990
541
to be consistent and integrated; there would be some
individuals who belonged to all three groups.
THE COMMUNITY
To alert and educate the community, messages
were sent over a variety of channels to reach iden-
tified risk groups, i.e. children (the highest risk
group); employee groups; and the community at
large. The community messages included basic in-
formation about the disease and the identified vec-
tor; ways to avoid exposure; proper methods of tick
removal; signs and symptoms to look for; and in-
structions to seek medical advice immediately if in
doubt.
Risk Group 1 — Children. Children were accessed
through schools, summer camps, and clubs. In the
early spring, half-day seminars on Lyme disease
were conducted for school nurses. Teachers were
provided with a teaching supplement developed in
conjunction with several business and educational
groups. Classroom activity sheets were developed
and distributed. Speakers were made available to
parent/teacher groups and students. A tickbusters
tee-shirt was developed and children were en-
couraged to become tickbusters. A video was
produced with two children showing methods of de-
fensive dressing. Large tabletop displays were con-
structed and rotated on loan throughout the school
system.
Speakers made presentations at meetings of Girl
Scouts, Boy Scouts, and other interested youth
groups; videos and the tabletop displays were made
available to program directors.
Because the Health Department provides operat-
ing permits for private and public summer camps
in Westchester County, it was mandatory for camp
directors to attend a day-long workshop on camp
safety prior to the beginning of each camp season.
A session on the recognition and prevention of Lyme
disease was a required component of that seminar.
At summer camp inspections, sanitarians from the
Department talked to camp counselors, reinforcing
the messages given the camp directors during the
preseason workshops, and literature was presented
for the counselors and campers.
Risk Group 2 — Employees. Employee groups
were accessed at their place of employment. Educa-
tional programs were presented by staff, particularly
to those at high occupational risk, such as parks and
public works employees, or those whose* place of em-
ployment was in a high risk area.
Risk Group 3 — General Public. Several ap
proaches were used to reach the general public. An
intensive campaign was initiated to attract broad
media coverage. Press releases were generated,
photo opportunities were created, and reporters were
invited to go out into the field and were provided
Adult male and female deer ticks.
with photos of ticks, as well as live and preserved
specimens.
Key staff appeared on news programs. During
summer 1988, the health commissioner was inter-
viewed on CBS Nightline and on the McNeil/Lehrer
news hour. In addition, a number of national maga-
zines, including Sports Illustrated, Good House-
keeping, Self, and Consumer Reports wrote articles
on this program.
Public forums were conducted in the evenings dur-
ing the peak Lyme disease seasons in areas of high-
disease prevalence. The forums provided op-
portunities for the public to ask questions and with
media coverage, had an impact beyond the group in
attendance.
In an effort to define the scope of the problem, a
tick surveillance and identification program was
begun in 1984. As a service to the community, ticks
sent to the Department were identified. This was
both educational and helpful in epidemiologic stud-
ies, confirming that most ticks were acquired on the
property of the resident, and that it was not neces-
sary to go into heavily wooded areas to acquire Lyme
disease. Surveys of Ixodes density in county parks
were initiated in 1985. The results of these surveys
were made available to the public and based on
these results, parks were posted during months of
high park use. Pamphlets on Lyme disease were
handed out by park staff and people were en-
couraged to stay in the areas that were well main-
tained as tick density was less in well-groomed areas.
In 1985, county veterinarians: reported cases of
Lyme disease in dogs and the occasional cat;
NEW JERSEY MEDICINE
542
Photo courtesy of Gibbs-Soell Public Relations.
provided speakers for the public forums; and dis-
tributed literature in their offices. The canine case
reports also were used as a surveillance tool in an
effort to predict the areas of the county most likely
to become hot spots for human cases. The theory was
that the dogs have greater potential for exposure and
were likely to be the first infected. Also, since dogs
are less wide ranging than humans, dogs probably
pick up the disease close to home and are an indica-
tion of the spread of the infected tick. This infor-
mation was used to alert residents in previously un-
infected areas of the county.
A Lyme disease hotline was established in 1985;
a taped message answered many of the commonly
asked questions about the disease and provided ad-
ditional telephone numbers where staff members
were available to answer specific questions.
The first Lyme Disease Awareness Week (LDAW)
was held in May 1987. A newspaper supplement,
available to school children, was developed in coop-
eration with the Gannet newspaper chain and Ciba-
Geigy Corporation. The second LDAW was held in
spring 1988, and was more successful. Many of the
materials developed were borrowed by surrounding
county health departments. In spring 1989, the effort
was expanded with the cooperation of the other re-
gional county health departments to have events
occurring simultaneously throughout the Lower
Hudson Valley during LDAW III.
HEALTH CARE PROVIDERS
Messages developed for health care professionals
emphasized the magnitude of the problem in West-
chester: signs and symptoms of the disease; the need
to include Lyme disease in the differential diagnosis
when considering a wide array of symptom complex-
es; and the need for early diagnosis and aggressive
treatment.
A day-long symposium for health care pro-
fessionals was held in conjunction with New York
Medical College in October 1984. At the opening of
the symposium, the commissioner of health declared
Lyme disease an epidemic in Westchester and made
it a locally reportable disease. Mailings then were
sent to physicians at the beginning of each Lyme
disease season, reminding them of the need to report
cases, and speakers were provided for local hospitals
as part of a continuing educational program.
A second seminar for physicians and health care
providers was held as part of LDAW II in May 1988;
the seminar was attended by over 250 physicians
from Westchester and the surrounding counties.
ELECTED OFFICIALS
The third and final component of the educational
campaign was directed at state health department
decision makers and the elected officials at the local,
state, and national level. The message for these indi-
viduals emphasized the magnitude of the problem,
the seriousness of the disease, the cost in human
suffering, and the health care costs and work lost
costs. High-ranking members of the state health de-
partment were invited to the first professional sym-
posium in 1984. Literature was provided to the sena-
tors and assemblymen who represent the areas hard-
est hit in the county. Presentations were made
before the health committee of the Westchester
Board of Legislators. Speakers were provided at eve-
ning public forums held by state legislators, and the
commissioner testified at hearings held by the State
Assembly Health Committee.
RESULTS
Schoolchildren and teachers participated enthusi-
astically in the educational campaign. Children
wrote letters and sent cartoons of ticks to the news-
papers and to the Health Department. Parents per-
formed nightly tick checks on their children in areas
of high-disease prevalence. A number of large em-
ployers provided programmatic and monetary sup-
port for our efforts in subsequent years. The Lyme
disease hotline attracted callers from all over the
country, particularly after it was discussed in Fam-
ily Circle magazine. Tabletop displays were in con-
stant demand and circulated through banks, li-
braries, schools, and hospital lobbies. Lyme disease
support groups were formed in heavily impacted
areas of the county, and Lyme disease has become
a frequent topic for CMF, lectures for physicians and
nurses. The county executive and several staff mem-
bers participated in Lyme Disease Awareness Week,
and the county executive requested a budgetary
“add on” from the Board of Legislators for 1987 to
enhance the Health Department’s programs. As a
result of all our efforts, $125,000 was added in fiscal
1987 for education and testing. Additionally, state
legislators earmarked $700,000 in the 1988 state
budget for Lyme disease research, and these funds
were continued in 1989. In 1989, federal funds be-
came available.
CONCLUSION
Public health education and behavior modi-
fication campaigns take time and effort. If well
planned and incrementally implemented over time,
these programs can be successful and have a direct
impact on the prevention of disease.
Much has been learned about Lyme disease over
the past ten years. Public awareness campaigns have
focused the attention of local, state, and federal de-
cision makers on this growing problem. With grant
support now available to researchers, the next ten
years may provide us with the tools needed to pre-
vent the disease and control the vector. ■
VOL. 87— NUMBER 7 JULY 1990
543
Psychological Impact
of Media Coverage
of Lyme Disease
MARY E. SWIGAR, MD
The author assesses the psychological impact of media coverage of Lyme
disease from global and symbolic perspectives. Additional information sug-
gests useful changes for the media, medical educators, and the public.
Consider Figure 1. The information provides
a liberal psychological impact.* 1 Media cov-
erage of Lyme disease almost is as much
with us as our shadows. The real questions are: Is
the psychological impact of media coverage man-
aged well? Is the media aware of its responsibilities?
Are we seeking and using information responsibly?
Is the smiling person at the center of Figure 1 a false
symbol or a symbol of the survival and adaptability
of the human spirit? As is shown in Figure 1, we have
much about which to worry.
In its psychological impact, media coverage about
Lyme disease is affected by the context in which we
live, with our concerns and dreads. What might the
media consider Lyme disease to be on a symbolic
level, in addition to the facts about it? And how
might the symbolic level be better managed?
Lyme disease is spread by the bite of a very tiny
Dr. Swigar is associate professor, Department of Psy-
chiatry, UMDNJ-Robert Wood Johnson Medical School,
and chief of psychiatry, Robert Wood Johnson University
Hospital. Requests for reprints may be addressed to
Dr. Swigar, Robert Wood Johnson University Hospital,
1 Robert Wood Johnson Place, MEB 268, New Bruns-
wick, NJ 08903.
tick. It is visible only with difficulty to the naked
eye. Symbolically, it is a barely visible insect in-
festation of our person. This conjures up images of
having lice or fleas or of being insect ridden — of
being made unclean and swarmed by a poorly under-
stood invader, then being injected with something
noxious. In fact, as a consulting psychiatrist, one
sees this as a common human dread. People halluci-
nating in delirium feel they have insects crawling on
them. It used to be that dogs and occasionally hu-
mans had ticks — a nuisance and a bit of a joke.
Looking for this tiny tick could resemble an ob-
sessive compulsive disorder — the minute detailed
examination of every inch of skin for this bug. It also
could become a different bug phobia.
Another symbolic level is the primitive dread of
our forests. Only now, instead of dreading a large
rampaging animal, we dread a tiny insect. We ob-
sessively spray and cover ourselves. But this also ties
into our fears and concerns for environmental haz-
ards— are our forests preserved and safe?
Lyme disease is spread by a tick-borne spirochete,
Borrelia burgdorferi.2 It is a spirochete similar to
Treponema pallidum, the spirochete causing syph-
ilis. In fact, there is serologic cross-reactivity in
diagnostic tests.3 Furthermore, there are chronic
544
NEW JERSEY MEDICINE
Nuclear Proliferation
Figure 1. Lyme disease in the context of an unpredictable world.
symptoms and signs in common for all spirochetal
diseases. Thus, the same complex, progressive sys-
temic illness with a wide variety of manifestations
is true of syphilis and Lyme disease.
It is a complex task for the individual, the media,
and the average physician to become educated about
an acquired, preventable illness, whose symptoms
acutely are rash and flu, and then could resemble
rheumatoid arthritis, multiple sclerosis, or psy-
chosis. Symbolically, this means hidden, acquirable
danger. Chronic disease, deformity, and disability
Figure 2. Learning about Lyme disease.
potentially could result from a single instance of
venturesomeness, recklessness, or lack of care.
We are reminded of a dangerous world by micro-
scopic avengers. We have our primitive roots, but we
also have an accelerating civilization and can inform
ourselves. Physicians experience the impact of vari-
ous information sources patients use (Figure 2).
Further, forces of consumerism and modern medical
care systems make patients demand more.
Is there published evidence that the popular
media has responded to the need to participate in
responsible medical education? The answer is
simple: not regarding Lyme disease. However, a
large evaluation study of print media by the Rand
Corporation and UCLA published in JAMA sug-
gested that balanced and accurate reporting exist on
topics such as coronary artery bypass, estrogen use,
caesarean birth, and breast cancer.4
Science inherently is difficult, requires time to be
done properly, and does not lend itself to presen-
tation in brief. However, when the media present
new and dramatic results from the latest medical
journal issues, they should also teach that the results
require replication and validation. There is much to
be done in general public education about medical
science and the scientific method.5 Public advertis-
ing can provide dear and useful scientific infor-
mation for products.6 Education of middle manage-
VOL. 87— NUMBER 7 JULY 1990
545
Figure 3. Learning about Lyme disease supplemented.
ment personnel in the media, in medicine, and in
product advertising is key to conveying a general
understanding of science.* 5 6 7
The media added medical information specialists
within their organizations (Figure 3). However, trust
and compromise must be established between medi-
cal scientific educators and these media specialists.
Resisting using catchy but inaccurate leads, mis-
quoting and preinterview hidden bias could be
avoided by the media. Physicians and scientists
need to be succinct yet convey complexity, be avail-
able, provide background reading, and recheck copy.
They also should be aware that a 20 minute inter-
view might be condensed to 45 seconds.
An interesting evaluation study of the public’s
perceptions of information is available from Lon-
don.8 A representative group of television viewers
were asked their responses to a spectrum of three
shows on health. The spectrum was varied from soap
1. BehrRL, Iyengar S: Television news, real-world cues,
and changes in the public agenda. Pub Opin Quar
49:38-57, 1985.
2. Benach JL, et al . : Spirochetes isolated from the
blood of two patients with Lyme disease. N Engl J Med
308:740-742, 1983.
3. Magnarelli LA, et al.: Cross-reactivity in serological
tests for Lyme disease and other spirochetal infections. J
Infect Dis 156:183-188, 1987.
4. Winkler JD, et al.: Popular press coverage of eight
National Institutes of Health consensus development
opera, light talk show, and heavy but cynical drama
series. Interestingly, viewer confidence about the
health information provided in each show followed
a U-shaped curve. Those viewers that did not watch
and those viewers that thoroughly followed the pro-
grams had the most confidence in the medical infor-
mation and treatments presented. Those viewers fol-
lowing the programs somewhat had the most skep-
ticism. If these conclusions are correct, viewers plan-
ning to watch a medical information program should
follow it as thoroughly as possible.
CONCLUSION
I have attempted to place the psychological im-
pact of media coverage in both a global and symbolic
context — in general and specifically about Lyme dis-
ease. I have presented information and suggestions
for change from media, medical, and public systems’
perspectives. ■
topics. JAMA 255:1323-1327, 1986.
5. Gregory RL: The public perception of science- 1. Per-
ception 15:231-233, 1986.
6. Gregory RL: The public perception of science-3. Per-
ception 15:511-514, 1986.
7. Cranshaw R: Second thoughts: Medicine and the
media. J Clin Epidemiol 42:815-816, 1989.
8. Wober M, Gunter B: Televison and beliefs about
health care and medical treatment. Curr Psychol Res Rev
291-304, 1985.
546
NEW JERSEY MEDICINE
Clinical Manifestations
of Lyme Disease
LEONARD H. SIGAL, MD
The author discusses the clinical manifestations of Lyme disease, a multi-
system inflammatory illness with protean symptomatology. The author also
presents a brief historical review of the disease.
Lyme disease is a multisystem inflammatory
disease caused by the spirochete, Borrelia
burgdorferi, and spread by Ixodes ticks. In
1975, Steere described Lyme arthritis, an outbreak
of juvenile rheumatoid arthritis, in three small
towns on the east bank of the Connecticut River.
Some of these patients recalled an expanding red
rash, identified as erythema chronicum migrans
(ECM).1 The first report of ECM in the United
States was in 1970, by Scrimenti, in Wisconsin,
although the lesion had first been described in
Europe in 1909. 2 The outbreak of juvenile
rheumatoid arthritis in Connecticut also was linked
Dr. Sigal is assistant professor, Departments of Medicine
and Molecular Genetics and Microbiology, UMDNJ-Rob-
ert Wood Johnson Medical School. Requests for reprints
may be addressed to Dr. Sigal, UMDNJ-Robert Wood
Johnson Medical School, 1 Robert Wood Johnson Place,
MEB 484, New Brunswick, NJ 08903-0019.
to preceding ECM and tick bites, and over the next
few years, Lyme arthritis, as it was first named,
became known as Lyme disease. This occurred, in
part, because of the association with cardiac disease,
but also because approximately 10 percent of the
patients had a neurologic syndrome essentially
identical to a tick-borne neurologic syndrome in
Europe, known as Bannwarth’s syndrome. The
multisystem, inflammatory nature of Lyme disease,
a multifocal epidemic, was established.
Today in the United States, Lyme disease is iden-
tified as a multifocal epidemic disease in the North-
east (from Massachusetts through Pennsylvania,
with cases described as far south as the Carolinas
and Georgia); the northern Midwest (primarily
Minnesota and Wisconsin, as well as Michigan), and
in northern California and Oregon. Ninety percent
of the cases reported in the United States are from
these three regions, and the total number has in-
VOL. 87— NUMBER 7 JULY 1990
549
creased steadily each year. This increase in cases is
especially notable in New Jersey, second to New
York in newly reported cases of Lyme disease.
After B. burgdorferi was identified as the etiologic
agent of Lyme disease in the United States, studies
in Europe established that the same organism was
the cause of ECM in Germany, Austria, and Scan-
dinavia. In addition, two other skin lesions reported
in Europe from the late 19th century, acrodermatitis
chronica atrophicans (ACA) and lymphadenosis
benigna cutis (LABC), and tick-borne meningo-
polyneuritis, or Bannwarth’s syndrome, were estab-
lished as being caused by infection with the same
organism.
Lyme disease now is known to have a worldwide
distribution, with cases described in Africa, Asia,
and Australia. The primary vector in each area has
been identified as an Ixodes tick: I. dammini in the
Northeast and Midwest, I. scapularis in the
Southeast, I. pacificus in California, I. ricinus in
Europe, I. persulcatus in Asia, and, possibly,
I. hyocyclus in Australia.3'5
Lyme disease is an infectious disease capable of
causing damage to a number of organ systems.6,7
Stage one of the disease occurs within a month of
inoculation with B. burgdorferi, the causative agent
of Lyme disease.8'10 The clinical syndrome at this
stage includes ECM, the skin rash, and associated
symptoms. Stage two of Lyme disease, which in-
cludes cardiac and/or neurologic disease, usually oc-
curs two to three months after the initial infection,
occasionally in the absence of any preceding
evidence of illness suggestive of stage one. Stage
three includes arthritis and/or chronic neurologic
manifestations that recently have been described;
these stage three manifestations may occur years
after ECM, but may appear in the absence of any
preceding history suggestive of earlier Lyme disease.
Stage one occurs between 1 day and 1 month after
tick bite (median 7 days) and consists of ECM and
associated symptoms: fever, fatigue, malaise, head-
ache, stiff neck, arthralgia, and myalgia. About 50
to 70 percent of patients will experience ECM and,
of these, 50 percent of patients will have more than
one skin lesion. Regional (and occasionally systemic)
lymphadenopathy may occur. Patients may develop
pain on neck flexion, conjunctivitis, erythematous
throat, temporomandibular joint pain, and
hepatosplenomegaly and/or right upper quadrant
tenderness.11
Nonspecific laboratory studies, like erythrocyte
sedimentation rate, complete blood count, and liver
function tests, are abnormal in between 20 and 50
percent of cases, but are not helpful in diagnosing
Lyme disease.11 Early in the disease, specific
serologic tests may be negative and seropositivity
may not occur until six to eight weeks into the ill-
ness.12,13 B. burgdorferi has been cultured from biopsy
specimens taken at the expanding red border of the
ECM lesion.8
Two to three months following the onset of ECM,
about 10 to 15 percent of untreated patients with
stage one Lyme disease will experience neurologic
disease. Meningoencephalitis, meningitis, cranial
nerve palsies, and peripheral neuropathies may
occur, often in combination, and often accompanied
by extreme fatigue, malaise, headache, and photo-
phobia.14'16 Fever usually is absent. Mild encepha-
lopathy, including difficulty with concentration and
memory, and irritability and emotional liability may
occur. These neurologic findings are essentially
identical to those described in Europe, in the early
part of this century and now known as Bannwarth’s
syndrome17 or tick-borne meningopolyneuritis.18
A lymphocytic pleocytosis is found in the
cerebrospinal fluid, with elevated protein, but nor-
mal glucose levels.14,16 The spinal fluid is normal in
stage one Lyme disease, even in the presence of
headache; a few cases have had serial lumbar punc-
tures, demonstrating that meningoencephalitis of
stage two disease evolves. The meningitis of Lyme
disease is indistinguishable from that of enterovirus,
virtually epidemic in the state in the early fall. Bor-
relia burgdorferi has been grown from the
cerebrospinal fluid of patients with Lyme men-
ingitis.8
Neuropathic changes have been found on nerve
conduction testing;14 axonopathy was documented in
one third of patients with peripheral neuropathy.19
Peripheral nerve biopsies have shown heavy
epineural vessel infiltration with mononuclear
cells,19'23 but the organism has not been found at the
site of inflammation. Vasculitis was seen in one
case;20 luminal obliteration of perineural vessels
without vasculitis was found in another case.21 Im-
mune complexes, immunoglobulin, and complement
have not been seen in biopsy specimens.19,20
Vascular disease caused by B. burgdorferi may be
the underlying mechanism for one report of
cerebrovascular disease24 and vasculitis has been
seen on angiographic study of one patient with Lyme
disease central nervous system (CNS) disease.25
Most patients with encephalitic symptoms have
abnormalities on electroencephalography14 and re-
versible neuropsychiatric testing abnormalities have
been documented;19 in some patients, small plaques
have been found on magnetic resonance imaging
(MRI), occasionally resolving after antibiotic ther-
apy.19 An insufficient number of normal individuals
have had MRI to know if these plaques represent B.
burgdorferi- induced cerebral damage or if normal
individuals may have such plaques. In collaboration
with Dr. Jonathan Willard-Mack, a neuropsy-
chologist at UMDNJ-Robert Wood Johnson Medical
550
NEW JERSEY MEDICINE
School, and Dr. Robert Chabot, a clinical elec-
troneurophysiologist at New York University School
of Medicine, the staff of the Lyme Disease Center
at UMDNJ-Robert Wood Johnson Medical School
is studying this population; we have found there to
be widespread, often severe, abnormalities on both
neuropsychologic testing and quantitative elec-
troencephalography, some of which may resolve
after therapy.
Cardiac disease occurs in 8 to 10 percent of
previously untreated patients, two to three months
after ECM, occasionally in coincident with stage two
neurologic disease. Atrioventricular conduction de-
fects, mild congestive heart failure, and ST and T
wave changes compatible with myopericarditis have
been reported.26 Reversible27'29 and rarely fatal30
myocarditis has been described. The multifocal
damage documented in electrophysiologic studies of
individual cases is likely the explanation for the
multiple levels of heart block occasionally described,
in rapid succession, in individuals with Lyme dis-
ease carditis.2629 Focal myonecrosis and a sparse in-
terstitial infiltrate of polymorphonuclear cells and
lymphocytes was described in one series of
myocardial biopsies,21 while B. burgdorferi,
myonecrosis, and perivascular mononuclear cell in-
filtration was found in another.29 The finding of an
organism within the myocardium suggests that
direct invasion occurs in Lyme myocarditis.30
Arthritis is the classic feature of stage three Lyme
disease,31 and the reason the first epidemic of Lyme
disease was described 15 years ago. Steere sum-
marized experience with 55 patients with Lyme dis-
ease who did not receive antibiotic therapy. These
patients had been infected before the efficacy of
antibiotics had been appreciated, so they represent
the only collection of patients where the natural
evolution of Lyme arthritis has been studied.32 A
prospective study of these patients revealed that 44
patients (80 percent) experienced articular problems
over the course of a six-year period. This included:
10 patients (18 percent) who experienced arthralgias
with or following ECM, one day to eight weeks
(mean, two weeks) after the onset of the lesion; 28
patients (51 percent) with polyarthritis, often mi-
gratory, present four days to two years after the
onset of ECM (mean, 6 months); 14 patients with
preceding migratory arthralgias; and 6 patients (11
percent) with chronic Lyme arthritis, usually affect-
ing a single joint (most often the knee), with onset
4 months to four years after ECM (mean, 12
months). Five of these 6 patients had experienced
either arthralgia or intermittent arthritis prior to
developing chronic synovitis. The migratory poly-
arthritis group is reminiscent of the original cohort
of patients described by Steere.1
The synovium in Lyme arthritis resembles
rheumatoid synovium,21'31,33 although there are dis-
tinct differences between rheumatoid and Lyme syn-
ovitis.21 In Lyme disease, there is hypertrophy and
hyperplastic changes, with focal necrosis, vascular
proliferation, and chronic inflammatory cell infiltra-
tion. Mononuclear cell aggregates and lymphoid
follicles may be present, suggesting that there is an
ongoing local immunologic reaction within the
joint.34 As in syphilis, endarteritis obliterans may be
seen, with capillary arborization, dilatation, and
congestion.33 B. burgdorferi has been seen rarely in
or near synovial vessels33 or in synovial fluid,35 and
has been grown from synovial fluid.36
Tertiary neuroborreliosis is a term that purposely
draws upon the clinical analogy with tertiary neu-
rosyphilis. This late form of Lyme disease includes
chronic encephalomyelopathy and neuropathy,37'39
and, like tertiary neurosyphilis, stage three neu-
rologic Lyme disease may develop insidiously
months to years after the onset of infection, even in
the absence of clinically apparent preceding infec-
tion. Subclinical infection thus may occur for long
periods prior to the emergence of overt neurologic
damage; this raises serious concerns over the finding
of asymptomatic seropositivity in a significant per-
VOL. 87— NUMBER 7 JULY 1990
551
cent of people in areas endemic for Lyme disease.
Clinical experience with this population is limited,
and the true clinical spectrum of this stage of Lyme
disease currently is being defined. Claims that
amyotrophic lateral sclerosis,40 multiple sclerosis,41
and Alzheimer’s disease42 are due to infection with
B. burgdorferi have been laid to rest. Many individ-
ual cases of neurologic damage have been stated as
due to B. burgdorferi infection merely because the
patient has a positive serologic test, a circumstance
that does not guarantee causality.
One of the major controversies in the study of
Lyme disease is the question of what clinical con-
ditions can be ascribed to B. burgdorferi infection.
On the basis of sero-epidemiologic and biopsy
evidence, it has been suggested that a number of
cutaneous lesions, including morphea, lichen
sclerosus et atrophicus, eosinophilic fascitis, and
other cutaneous fibrotic disorders, are due to B.
burgdorferi, although these claims are by no means
definitive.43 Subclinical or asymptomatic infection
may be quite prevalent in endemic areas, so that
seropositivity may represent no more than a coin-
cidence.
Another area of major concern relates to B.
burgdorferi infection occurring during pregnancy.
Shortly after the Lyme disease epidemic in the
Northeast was appreciated, reports of adverse out-
comes of pregnancy began to appear. In a review of
19 pregnancies between 1976 and 1984 complicated
by Lyme disease, 14 normal births and 5 adverse
outcomes were noted.46 49
Also, there is no evidence that Lyme disease can
be passed by sexual or other intimate contact. There
is evidence, however, that B. burgdorferi can survive
in blood50 and various blood products51 for as long
as six to eight weeks. Whether Lyme disease can be
spread by transfusion is unclear.52
Lyme disease diagnosis can be aided by the use
of serologic and cellular testing. However, Lyme dis-
ease remains a clinical diagnosis. In the absence of
a set of well-substantiated criteria for the diagnosis
of Lyme disease, i.e. Jones’ criteria for rheumatic
fever, there is no substitute for a careful history and
physical done by a well-prepared health care
provider, and confirmed by serologic evidence of
preceding infection.
Antibiotic therapy in stage one disease usually
results in resolution of disease and prevents pro-
gression to later stages. Oral therapy is recommend-
ed for early disease. Even for severe stage one dis-
ease, there is no evidence that intravenous drugs are
necessary. The only comparative study of antibiotic
therapy in early disease suggested that either peni-
cillin or tetracycline was more effective than
erythromycin (1,000 mg in four divided doses for 10
days) in preventing progression to later disease; 20
days of tetracycline was no better than 10 days of
treatment.53 There are many proposed antibiotic
regimens for early disease, and there is no evidence
that one drug is superior to another. Tetracycline,
amoxicillin, ampicillin, and penicillin have been
used with good success, at doses of between 1,000
and 2,000 mg per day, in four divided doses; dox-
ycycline at 100 mg two or three times a day also is
effective. There is no evidence that the addition of
probenecid to therapy with the penicillins is neces-
sary to increase efficacy of penicillin therapy. Other
agents, including cefuroxime axetil, cefixime, and 1
minocycline have been used; initial studies of
azithromycin, a new macrolide antibiotic with
greater anti-B. burgdorferi activity than erythromy-
cin, are encouraging.
The optimum duration of therapy has not been
determined, although current practice generally is to
treat for three to four weeks.
There may be a remarkable worsening of signs and
symptoms of disease,53 often accompanied by fever,
chills, malaise, headache, and myalgia, in approx-
imately 15 percent of patients, within a few hours
to days of the onset of therapy. This may be accom-
panied by a rise in the peripheral blood white cell
count, and occasionally by increases in liver function
tests. All of these abnormalities are relatively mild
and usually resolve within a day or so. This
phenomenon was first described in syphilis, and is
known as the Jarisch-Herxheimer reaction. Such re-
actions also may be experienced early in the therapy
of other borrelial infections, and of brucellosis, where
the reaction may be life threatening. It appears that
antibiotic therapy causes the disruption of many of
the organisms and causes the liberation of many
borrelial components. When these circulating pro-
teins, polysaccharides, and lipids are identified by
the immune system, there is a sudden, systemic
response, with exacerbation of symptoms — the
Jarisch-Herxheimer reaction.
If untreated, ECM spontaneously will resolve in
a median of 28 days, although it may persist for as
long as 14 months. Progression to later disease is
most frequent in patients with more serious early
manifestations,32,54 but progression may follow mild
or inapparent stage one Lyme disease.55
Oral or parenteral antibiotics are effective in
treatment of stage two Lyme disease; the suggested
route, dose, and duration of therapy varies with the
type of manifestations.14'30'42'53'56
The arthritis of Lyme disease generally is treated
with intravenous antibiotics, including penicillin (20
million units per day in six divided doses), cefotax-
ime (3 g twice a day), and ceftriaxone (1 g twice a
day). Chloramphenicol, at doses appropriate to body
mass, also is effective in the treatment of Lyme
disease. In 55 percent of the cases reported by
552
NEW JERSEY MEDICINE
Steere,57 Lyme arthritis was treated successfully
with intravenous penicillin. B. burgdorferi is
sensitive to ceftriaxone and this agent has been used
successfully.58 One study suggests that subsequent
treatment with ceftriaxone is effective in patients
who have failed to respond to penicillin.58 There is
preliminary evidence to suggest that prolonged oral
therapy (one month) may be effective in treatment
of late disease but these studies must be confirmed.59
The most appropriate regimen for the treatment
of stage three neurologic disease probably is in-
travenous antibiotics, as used for the other late
manifestations of Lyme disease. There is not enough
clinical experience to be definitive about this, how-
ever, or to know if late neurologic damage is totally
reversible. There are anecdotes that claim slow, but
impressive, resolution.
Based on the premise that B. burgdorferi is a slow-
growing organism, some groups have suggested that
therapy for late Lyme disease should include in-
travenous courses for six weeks or longer and
prolonged oral maintenance therapy, up to 18 to 24
months. At this time, there is no proof that these
regimens are any more effective than the more tra-
ditional approaches; there is every reason to believe
that the longer regimens are associated with more
side effects and more expense to the patient.
One argument in favor of more prolonged therapy
is the persistence of symptoms and the occasional
apparent “progression” to later manifestations,
often in the presence of persisting elevated levels of
anti-B. burgdorferi antibody. The general ex-
perience has been that it may take six months or
longer for arthritis to fully resolve after antibiotic
therapy;57 persisting nonspecific symptoms may
occur after therapy of other manifestations of Lyme
disease. This may be due to the persistence of B.
burgdorferi- derived antigens at the site of disease,
serving as a focus for prolonged inflammation.34 Our
experience suggests that some patients develop
symptoms after Lyme disease (including
fibromyalgia) that are not due to ongoing infection
and are not amenable to further antibiotic therapy.60
Many patients referred to the Lyme Disease Center
at Robert Wood Johnson Medical School have been
subjected to many, unnecessary courses of oral and
intravenous therapy for complaints clearly not due
to persisting or new B. burgdorferi infection, but
which have been mistakenly attributed to Lyme dis-
ease.60 It is crucial to recall that not every complaint
in a patient who has had Lyme disease (or, for that
matter, in an individual with serum antibodies to B.
burgdorferi) is necessarily due to B. burgdorferi in-
fection.
The one indisputable fact is that the earlier a
patient is treated, the less likely that person is to
progress to later manifestations of Lyme disease.
The overwhelming majority of patients with treated
stage one Lyme disease will experience a cure. Fatal-
ities due to B. burgdorferi infection are very rare.
The only Lyme disease fatalities reported in the
English language literature were due to carditis
[although in one, coexisting babesiosis complicated
the clinical picture30] and possibly due to adult res-
piratory distress syndrome related to Lyme disease.61
There also is a brief French report of a fatal case of
Lyme meningoradiculitis, complicated by enceph-
alitis and phrenic paralysis.62 Nonfatal permanent
heart block due to Lyme disease was reported from
the Netherlands,63 but all other cases of conduction
defect have been reversible. Lyme meningitis re-
solves with antibiotic therapy.56
Lyme arthritis has proved somewhat less respon-
sive to antibiotic therapy. In the initial report, 55
percent of patients treated with intravenous peni-
cillin resolved; later studies suggest a better
response rate to therapy with third-generation
cephalosporins, including cefotaxime and ceftriax-
one. Nonetheless, some patients have required other
forms of treatment, including hydroxychloroquine
(as a remittive agent) and synovectomy.6 An under-
standing of the immunopathogenesis of this disease
is helpful in appreciating the persistence of inflam-
mation and symptoms in some patients; a full review
of this topic is beyond the scope of this paper, but
can be found elsewhere.34
A controversial issue in the therapy of Lyme dis-
ease is the status of asymptomatic people who hap-
pen to test positive for antibodies to B. burgdorferi.
It is not known how many, if any, of these people
ever will experience tissue damage due to this infec-
tion. The policy at the Lyme Disease Center is that
if a true seropositive result is obtained on an individ-
ual without any preceding history of Lyme disease,
oral therapy for one month, as for stage one disease,
is given.
Should a tick be found on your patient it should
be removed with thin tweezers or forceps, using anti-
septic precautions. Old wives’ tales suggest that
kerosene, petroleum jelly, or a lit match or cigarette
are effective in tick removal; these methods should
be eschewed, as they may cause the tick to act as
a syringe and regurgitate into the wound, causing
transfer of B. burgdorferi.
Even if an engorged tick is found, it is estimated
that in an endemic area only 10 percent of tick bites
actually transmit the disease.64 This suggests proph-
ylactic antibiotic therapy of all tick bites is not
necessary; in one study, the risk of adverse reactions
from the antibiotic therapy was as great as the risk
of seroconversion if no prophylaxis was given. If this
experience is extrapolated to repeated prophylaxis of
large numbers of residents in endemic areas, the cost
and potential morbidity of therapy would be tremen-
VOL. 87— NUMBER 7 JULY 1990
553
dous; in some endemic areas, individuals would be
on constant antibiotic prophylaxis from April to Oc-
tober for their repeated tick exposures. In addition,
prophylactic therapy may give a false sense of secur-
ity and lead individuals to abandon preventive tech-
niques. Our suggestion is that if no skin rash de-
velops and no signs or symptoms suggestive of Lyme
disease develop, the bitten individual should return
for blood testing at six to eight weeks after the bite;
if seropositive, the patient then can be treated with
an oral regimen. Some suggest that a blood test done
at the time of the bite is indicated. True seropositivi-
ty would suggest prior exposure to B. burgdorferi,
and, if treatment of asymptomatic seropositivity is
considered advisable, therapy could be started at
that time.
CONCLUSIONS
Lyme disease has been described by the press and
broadcast media as being the scourge of the 1980s
and 1990s; reporters speak of Lyme disease as being
second to AIDS as a public health problem in the
United States. Well-meaning physicians have stated
that prolonged and repeated therapy is necessary to
suppress Lyme disease, and that rarely, if ever, is
it cured. Reports of medical problems thought due
to B. burgdorferi infection appear in the medical
literature, supported by only a positive serologic
test. The tests practitioners use to document ex-
posure to B. burgdorferi have been unfairly derided
as being nearly useless, because of cross-reactivity,
inaccuracy, and lack of standardization. The end
result has been that patients in endemic areas often
feel their physicians do a poor job of diagnosing and
treating Lyme disease, that the tests and thera-
peutic agents are profoundly flawed, and that Lyme
disease should represent a real cause for alarm.65
Given the perception by many patients of Lyme
disease as a mysterious, difficult-to-diagnose dis-
ease, with an ever-expanding and poorly defined,
clinical spectrum, it is not surprising that many
patients have seized upon Lyme disease as the ul-
timate explanation for all of their ills. It is no wonder
that many patients view Lyme disease with alarm,
bordering on hysteria.
Lyme disease has become a major health concern
in a growing number of communities. Much has
been learned about the disease, although much
study is needed. The problem is manageable, if we
can convince all of our patients that Lyme disease
is a cause for concern, not panic; vigilance, not hys-
teria. ■
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555
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Lyme Disease
During Pregnancy
SANDRA J. EDLY, MD
Lyme disease during pregnancy has been associated with a variety of
adverse pregnancy outcomes.
Infectious diseases during pregnancy can have
an adverse effect on pregnancy outcome. Tox-
oplasmosis, rubella, cytomegalovirus, and
herpesvirus are capable of being transplacentally
transmitted to the fetus and have known teratogenic
potential. Treponema pallidum, the etiologic agent
of syphilis, also can cross the placenta and can lead
to overwhelming infection of the fetus. Lyme dis-
ease, caused by Borrelia burgdorferi, and syphilis are
both spirochetal infections. Because of the
morphologic and antigenic similarities of B.
burgdorferi and T. pallidum, much concern has been
raised about the potential adverse effect Lyme dis-
ease may have during pregnancy. In addition,
another Borrelia, B. recurrentis, the cause of relaps-
ing fever, also has been implicated in congenital
infection and adverse pregnancy outcome.1
A maternal infection may be transmitted to the
fetus by transplacental transmission or by acquisi-
tion of the organism by the fetus during passage
through the birth canal. This latter route appears to
play no role in the transmission of perinatal Lyme
disease. Therefore, attention has been directed to
investigation of transplacental transmission of B.
burgdorferi, and its possible adverse effect during
pregnancy.
TRANSPLACENTAL TRANSMISSION
Transplacental transmission of Borrelia
burgdorferi has been documented. The first case re-
Dr. Edly is affiliated with the Department of Obstetrics
and Gynecology, UMDNJ-Robert Wood Johnson Medical
School. Requests for reprints may be addressed to Dr.
Edly, UMDNJ-Robert Wood Johnson Medical School,
New Brunswick, NJ 08903.
port of maternal-fetal transmission of Lyme disease,
reported by Schlesinger in 1985, 2 noted a woman who
contracted Lyme disease during the first trimester
of pregnancy that was not diagnosed and, therefore,
was not treated. The diagnosis of first trimester
Lyme disease eventually was made based on ma-
ternal history: the patient had developed an expand-
ing annular skin lesion, two secondary skin lesions,
headache, stiff neck, arthralgia, malaise, and in-
guinal lymphadenopathy after participating in out-
door activities in an area of Wisconsin known to be
endemic for Lyme disease. At 35 weeks’ gestation,
the patient was delivered of a 3,000 g male infant
who died 39 hours after birth of cardiac failure. The
infant had multiple cardiovascular anomalies in-
cluding coarctation of the aorta, aortic valvular
stenosis, patent ductus arteriosus, and endocardial
fibroelastosis. A few spirochetes morphologically
compatible with B. burgdorferi were seen in sections
of the infant spleen, renal tubules, and bone marrow,
but not in the heart. Maternal serology for B.
burgdorferi was positive, and was negative for syph-
ilis.
The second case of transplacental transmission of
Borrelia burgdorferi, reported by MacDonald in
1987, 3 was of a woman with first trimester Lyme
disease not diagnosed and not treated. The diagnosis
was made retrospectively based on maternal history
of an annular erythematous skin lesion in the first
trimester, followed by pain and swelling of the knee;
these resolved spontaneously. The patient took no
medications during her pregnancy except for digoxin
for mitral valve prolapse. At term, the patient was
delivered of a 2,500 g stillborn. An autopsy of the
infant showed a four mm ventricular septal defect.
VOL. 87— NUMBER 7 JULY 1990
557
No other congenital anomalies were noted. B.
burgdorferi was cultured from the fetal liver and the
spirochete also was seen in sections of the fetal brain,
adrenal gland, heart, liver, and placenta. Maternal
serology was positive for anti-B. burgdorferi anti-
bodies, and negative for syphilis.
MacDonald reported three other patients who had
transplacental transmission of Lyme disease with
evidence of B. burgdorferi infection in fetal tissue.4
Each of the three women had a second trimester
pregnancy loss, and B. burgdorferi was cultured
from the fetal liver in all three cases. None of the
patients had evidence of any antepartum infection.
In 1988, Weber reported a case of Borrelia
burgdorferi infection in a newborn despite treatment
of the mother with oral penicillin for Lyme disease
during pregnancy.5 The patient developed erythema
chronicum migrans (ECM) two weeks after she had
multiple tick bites in the first trimester. She re-
ceived a course of antibiotic therapy and the re-
mainder of her antepartum course was uneventful.
The patient was delivered at term by vacuum ex-
traction of a 3,400 g infant who appeared normal at
birth. However, the infant developed respiratory
failure and died 23 hours after birth. The cause of
death was reported as probably due to respiratory
failure as a result of perinatal brain damage. An
autopsy showed a large scalp hematoma, a small
infratentorial hemorrhage, as well as a few small
hemorrhages in the tentorium and falx cerebri.
There were no congenital malformations and no sig-
nificant inflammation was seen in the organs that
were available for examination. Spirochetes
morphologically compatible with B. burgdorferi
were seen in silver-stained sections of the brain and
liver. Although maternal serologic testing was
negative for anti-B. burgdorferi antibodies by in-
direct immunofluorescence, the maternal sera was
saved and tested several years later by enzyme-
linked immunosorbent assay (ELISA) which con-
firmed the presence of significant IgM antibodies
against B. burgdorferi. The authors of this report
contend that B. burgdorferi was persistent in fetal
tissue despite antibiotic treatment of the mother.
However, the patient was treated with propicillin
(an oral penicillin) three times daily for only seven
days; few if any authorities on the treatment of
Lyme disease would consider this adequate anti-
biotic therapy.
STUDIES OF
LYME DISEASE
The lirst study of Lyme disease during pregnancy
was reported by Markowitz in 1986. fi This study in-
cluded 19 pregnant women with Lyme disease dur-
ing pregnancy who were identified prior to knowl-
edge of pregnancy outcome; cases occurred between
1976 and 1984. Of 19 patients, 5 had adverse preg-
nancy outcomes (26 percent). Adverse outcomes in-
cluded intrauterine fetal death at 20 weeks’ gesta-
tion; preterm delivery at 36 weeks’ gestation and
neonatal hyperbilirubinemia; syndactyly; cortical
blindness with developmental delay; and rash of the
newborn. None of these adverse outcomes could be
directly attributed to Lyme disease infection. Thir-
teen of the 19 patients received antibiotic treatment
for their Lyme disease. Of the 6 patients who did
not receive treatment, 4 patients had a normal preg-
nancy outcome, and 2 patients had an adverse out-
come. Eight patients had onset of Lyme disease in
the first trimester, 7 patients in the second
trimester, and 2 patients in the third trimester; for
2 patients the trimester of onset was considered un-
known. There was no significant difference in out-
come by antimicrobial therapy or trimester of onset.
One patient of 19 with a second trimester preg-
nancy loss is more than the expected rate, however,
cultures of the fetus and placenta were negative for
Borrelia burgdorferi. One preterm delivery out of 18
(5.5 percent) is not unexpected. One child was
diagnosed as having cortical blindness with de-
velopmental delay at eight months of age, however,
the child tested negative for anti-B. burgdorferi anti-
bodies at one year of age.
While the number of adverse pregnancy outcomes
in this study is alarming, the authors concluded that
none of these outcomes could be directly attributed
to Lyme disease infection during pregnancy. How-
ever, serologic analysis of cord blood was not per-
formed for any of the infants subsequently identified
as having an adverse outcome. In addition, serologic
testing may not be the definitive diagnostic tool to
determine if the fetus has been exposed in utero to
B. burgdorferi, for serologic testing for Lyme disease
is far from perfect.
Williams reported a six-month pilot study of cord
blood testing of infants for Lyme disease antibodies
in both an area endemic for Lyme disease as well
as a control group from a nonendemic area.7 The
investigators tested cord blood samples at the time
of delivery from a total of 421 infants and recorded
the presence or absence of major and minor
malformations for each infant. Infant cord blood
specimens were collected from 255 infants born in
an area endemic for Lyme disease, of whom 10.2
percent had some detectable antibody to B.
burgdorferi. Of 166 infants tested from a non-
endemic area, 2.4 percent had some detectable anti-
bodies to B. burgdorferi. The rate of major and
minor malformations was not significantly different
between the two groups. In addition, there was no
increased rate of malformations in those infants who
did have detectable anti-B. burgdorferi antibodies
compared to those who were seronegative. The in-
558
NEW JERSEY MEDICINE
fants with detectable B. burgdorferi antibodies
tended to be of lower birth weight, to be smaller for
gestational age, and to have neonatal jaundice more
frequently than the infants born in the nonendemic
area; however these differences were not statistically
significant.
Since only live born infants were included in this
study, these results do not exclude the possibility of
an increased rate of congenital malformations in
areas endemic for Lyme disease. Congenital
malformations may have occurred in those preg-
nancies that resulted in spontaneous abortion or
miscarriage and these would have been preselected
from inclusion in this study. However, preliminary
data reported by Dlesk, from the Marshfield Clinic
in Wisconsin, showed no increased rate of spon-
taneous abortion in women with detectable Lyme
disease antibodies.8 Investigators tested
asymptomatic women from a Lyme disease endemic
area at first prenatal and postpartum visits for the
presence of anti-B. burgdorferi antibodies. Outcome
of pregnancy was recorded for each patient. At the
time of the preliminary report, 116 study patients
had completed pregnancies. Of these 116 patients,
12 patients had miscarriages (10.3 percent). Only 1
patient who miscarried tested positive for Lyme dis-
ease antibodies (8.3 percent). Of 104 women who did
not have a miscarriage, 13 women were Lyme disease
seropositive (12.5 percent). The authors preliminari-
ly have concluded that Lyme disease seropositivity
in the absence of symptoms of Lyme disease does
not have an important effect on the outcome of preg-
nancy, as patients who were seropositive for Lyme
disease antibodies did not have a higher rate of mis-
carriage. This study currently is ongoing and the
investigators plan to include approximately 1,000
patients in the final report.
Carlomagno reported preliminary results of a
study comparing the rate of Lyme disease
seropositivity in women who had a spontaneous
abortion to those who delivered at term.9 Of 49 con-
secutive patients who either had a first or second
trimester spontaneous abortion, 6 patients tested
seropositive for Lyme disease antibodies (12.2 per-
cent), compared to 3 of 49 women who delivered at
term (6.1 percent). Although more women were
seropositive from the spontaneous abortion group
compared to the group who delivered at term, these
differences were not statistically significant.
In 1989, Nadal reported results of a serological
survey of women and their infants at the time of
delivery for the presence of Lyme disease anti-
bodies.10 Over a one-year period, the investigators
tested 1,416 women and their 1,434 infants at the
time of delivery for the presence of anti-B.
burgdorferi antibodies. Only 12 of the 1,416 women
tested positive, giving a seroprevalance rate of 0.85
percent. Of the 12 women who had detectable Lyme
disease antibodies, only 1 woman (who had a tick
bite during pregnancy followed by ECM) had a his-
tory consistent with Lyme disease onset during preg-
nancy. Six of the 12 women had a history consistent
with pregestational onset of Lyme disease, and the
remaining 5 women had an unremarkable history.
Of the 12 women tested positive for Lyme disease
antibodies, 7 women were delivered of infants who
had a remarkable neonatal period. Two infants had
hyperbilirubinemia; one infant had muscle
hypotonia attributable to medication given to the
mother; one infant was post-term, small for gesta-
tional age, and had evidence of chronic placental
insufficiency; one infant had transient macro-
cephaly; and one infant had transient supraven-
tricular extrasystoles. The infant born to the woman
who had a first trimester tick bite and ECM had a
ventricular septal defect. However, the authors con-
cluded that since none of the infants were
seropositive for anti-B. burgdorferi antibodies, it was
unlikely that the adverse outcomes were due to
Lyme disease.
DISCUSSION
Information on the effect of Lyme disease during
pregnancy is incomplete, but conclusions can be
made based upon accumulated information.
Unlike the white-footed mouse, an important res-
ervoir of Borrelia burgdorferi, transplacental trans-
mission of Lyme disease does appear to occur in
human pregnancy. Unequivocal confirmation of B.
burgdorferi infection of the fetus by isolation of the
organism from fetal tissue obviously is limited to
those cases where fetal or neonatal death has oc-
curred. Despite this limitation, several cases of
transplacental transmission of B. burgdorferi have
been documented.
Lyme disease during pregnancy has been as-
sociated with adverse pregnancy outcome including
spontaneous abortion, miscarriage, stillbirth,
preterm delivery, hyperbilirubinemia, syndactyly,
cortical blindness with developmental delay, rash of
the newborn, and congenital cardiac anomalies. In
none of these cases was the adverse outcome of preg-
nancy directly attributable to Lyme disease. It is
possible that those adverse outcomes reported to be
associated with Lyme disease during pregnancy oc-
curred at a rate no different from the general popu-
lation, i.e. pregnant women without Lyme disease.
Without well-controlled studies, it is impossible to
determine if these adverse outcomes are occurring at
an increased rate due to Lyme disease infection, or
at the same rate as in the general population.
Furthermore, although a normal pregnancy out-
come with Lyme disease during pregnancy has been
reported, it is likely that cases of Lyme disease dur-
ing pregnancy that have resulted in normal preg-
nancy outcomes have not been reported as diligently
as those which have resulted in adverse outcomes.
If this is true, then the potential adverse effect of
Lyme disease during pregnancy would appear to be
less significant than suggested by case reports to
date.
Preliminary data from currently ongoing studies
have shown no increased rate of spontaneous
abortion, and no increased rate of congenital
malformations with Lyme disease during pregnancy.
However, there is an obvious need for controlled
studies of large numbers of patients to determine
conclusively the effect, if any, of Lyme disease infec-
tion during pregnancy. Unfortunately, there are
many difficulties faced by the investigator, not the
least of which is that serologic testing of the mother
and fetus may not be an accurate reflection of the
presence or absence of B. burgdorferi infection.
TREATMENT OF
LYME DISEASE
A standard for treatment of Lyme disease during
pregnancy has yet to be established. In 1988, the
Medical Letter included recommendations for treat-
ment of the pregnant patient that differed from
treatment of the nonpregnant patient only by ex-
cluding the use of tetracycline or doxycycline during
pregnancy.12 This guideline for the treatment of
Lyme disease recommended that patients be treated
according to stage or severity of disease. That is, oral
antibiotics were recommended for stage one and
mild stage two disease (early Lyme disease, ECM,
and mild neurologic disease), and intravenous anti-
biotic therapy was recommended for stage two dis-
ease unless mild, and for stage three disease (Lyme
arthritis).
Some physicians continue to treat pregnant pa-
tients with known or suspected Lyme disease more
aggressively than nonpregnant patients, treating all
1. Fuchs PC, Oyama AA: Neonatal relapsing fever due
to transplacental transmission of Borrelia. JAMA
208:690-692, 1969.
2. Schlesinger PA, Duray PH, Burke BA, et al.: Ma-
ternal-fetal transmission of the Lyme disease spirochete,
Borrelia burgdorferi. Ann Intern Med 103:67-68, 1985.
3. MacDonald AB, Benach JL, Burgdorfer W: Stillbirth
following maternal Lyme disease. NY State J Med
87:615-616, 1987.
4. MacDonald AB: Human fetal borreliosis, toxemia of
pregnancy, and fetal death. Zentralblatt Bakt Hygiene
263:189-200, 1986.
5. Weber K, Bratzke HJ, Neubert V, et al.: Borrelia
burgdorferi in a newborn despite oral penicillin for Lyme
borreliosis during pregnancy. Pediatr Infect Dis J
7:286-289, 1988.
6. Markowitz LE, Steere AC, Benach JL, et al.: Lyme
disease during pregnancy. JAMA 255:3394-3396, 1986.
pregnant women with intravenous therapy, irrespec-
tive of the stage of the disease. This approach is
apparently felt by some to be justified as an effort
to minimize any effect that Lyme disease may have
on the fetus. It would appear that the current data
available on the effect of Lyme disease during preg-
nancy does not warrant such intensive and costly
therapy in all pregnant patients.
When oral antibiotics are used, the most common
regimen is amoxicillin (500 mg three times daily) or
penicillin (500 mg four times daily) given for a period
of 21 or more days. When intravenous therapy is
prescribed, either penicillin G (20 million units daily
in divided doses given every four hours for two to
three weeks) or ceftriaxone (2 g once daily for two
to three weeks) is recommended. For penicillin al-
lergic patients, erythromycin can be used, but the
estolate form should be avoided as it has been as-
sociated with reversible, subclinical hepatotoxicity
in pregnant patients who took it for two to three
weeks. In addition, the efficacy of erythromycin in
the treatment of Lyme disease has not been clearly i
established, but it appears to be less effective than
other recommended antibiotics.
Prophylactic treatment of deer tick bites during
pregnancy continues to be controversial. Since the
chance of acquiring B. burgdorferi infection from a
tick bite has been estimated at about one in ten, the
universal treatment of all tick bites during preg-
nancy will result in unnecessary treatment for nine
of ten patients. One alternative is to prophy-
lactically treat women for tick bites during the first
and early second trimesters, since the fetus is most
susceptible to teratogens during this time, which
corresponds to the period of fetal organogenesis.
Finally, because Lyme disease is a preventable
infection, counselling patients about the signs and
symptoms of Lyme disease and measures that can
be taken to prevent infection should become a part
of routine prenatal care. ■
7. Williams CL, Benach JL, Curran AS, et al.: Lyme
disease during pregnancy: A cord blood serosurvey. Annals
NY Acad Sciences 539:504-506, 1988.
8. Dlesk A, Broste SK, Harkins PG, et al.: Lyme
seropositivity and pregnancy outcome in the absence of
symptoms of Lyme disease. Abstract #34, ICAAC, 1989.
9. Carlomagno G, Luksa V, Candussi G, et al.: Lyme
Borrelia positive serology associated with spontaneous
abortion in an endemic Italian area. Acta Europaea Fertil
19:279-281, 1988.
10. Nadal D, Hunziker UA, Bucher HU, et al.: Infants
born to mothers with antibodies against Borrelia
burgdorferi at delivery. Eur J Pediatr 148:426-427, 1989.
11. Mikkelsen AL, Palle C: Case report — Lyme disease
during pregnancy. Acta Obstet Gynecol Scand 66:477-478,
1987.
12. Medical Letter on Drugs and Therapeutics.
30:65-66, 1988.
560
NEW JERSEY MEDICINE
Neurological
Manifestations
of Lyme Disease
ANDREW R. PACHNER, MD
Neurologic involvement in Lyme disease often is seen in endemic areas.
Common manifestations, diagnostic tests, treatment, and prognosis are dis-
cussed and the importance of lumbar puncture is stressed.
The spector of neurological involvement in
Lyme disease looms large in areas endemic
for the disease. The clinician faced with the
patient with possible neurological Lyme disease
must rely on what is known about Lyme meningitis
and what is inferred to be true based on our under-
standing of the behavior of the spirochete in other
organ systems. In addition, we have centuries of
experience with manifestations of syphilis, and there
is growing evidence that Treponema pallidum and
Borrelia burgdorferi share a number of charac-
teristics, the most relevant of which is neurotropism.
The most common manifestation of Lyme disease
in the nervous system is Lyme meningitis, also
called Lyme meningoencephalitis, Bannwarth’s syn-
drome, or Garin-Bujadoux syndrome. The symp-
toms are caused by meningeal irritation from in-
flammation due to the presence of B. burgdorferi.
The spirochete has been cultured from the
cerebrospinal fluid (CSF) in some patients with
Lyme meningitis, and the symptoms are highly re-
versible with intravenous antibiotics. The “classi-
cal” triad of meningitis, radiculoneuritis, and
Dr. Pachner is associate professor of neurology,
Georgetown University School of Medicine, Washington,
DC. Requests for reprints may be addressed to Dr.
Pachner, Georgetown University School of Medicine,
3800 Reservoir Road, Washington, DC 20007.
cranial neuritis occurs only in a small percentage of
Lyme meningitis patients, and many patients have
a mild chronic meningitis with nonspecific symp-
toms of headache and stiff neck that may be quite
difficult to diagnose. Some patients develop a
seventh palsy with no CSF abnormalities.
The importance of lumbar puncture (LP) in the
diagnosis of neurological involvement in Lyme dis-
ease cannot be overemphasized. This infection rare-
ly causes significant structural damage; imaging of
the brain with computed tomography or magnetic
resonance imaging (MRI) scans is not helpful. There
is no characteristic abnormality on an electro-
encephalogram (EEG), and in patients with rela-
tively severe involvement, the EEG is normal. As in
many chronic infections of the nervous system, LP
is the most useful test. Although many patients,
especially those with relatively mild symptoms are
loathe to undergo LP, an explanation of the risks and
benefits of LP usually results in the patient accept-
ing the procedure. Most patients with neurological
involvement with Lyme disease will have a CSF
pleocytosis and/or an elevated protein, and common-
ly anti-B. burgdorferi antibody will be positive in the
serum and CSF. A normal spinal fluid is strong
evidence against the diagnosis of neurological Lyme
disease.
There has been much publicity about Lyme dis-
ease, and frequently the antibody assay is criticized
VOL. 87— NUMBER 7 JULY 1990
563
as being inaccurate and unreliable. There is some
truth to this, mainly because of a combination of
unrealistic expectations of the assay and a range of
quality in the performance of the assay by labora-
tories. Since there frequently is a mild or delayed
antibody response to the organism, antibody may
not be detectable for one to two months after infec-
tion. Thus, serology is definitely not a clinically use-
ful assay for erythema chronicum migrans. However,
by the time neurological involvement is present,
usually more than three weeks after infection, anti-
B. burgdorferi antibody titers are present and easily
detectable in the serum. The other major problem
with the assay is variability in the assay’s quality.
The government has not become involved in regu-
lation of the Lyme antibody assay, and there have
been a large number of laboratories providing the
assay to an anxious public. These laboratories range
in accuracy from excellent to atrocious, and it is
difficult for the practitioner to differentiate.
DIAGNOSIS
The diagnosis of Lyme meningoencephalitis gen-
erally is straightforward. In a patient suspected of
having this manifestation, LP is performed with
measurement of serum and CSF anti-B. burgdorferi
antibody. Patients with significant “encephalo-
pathic” complaints undergo neuropsychological
testing and those with neuropathic symptoms get
electromyography/nerve conduction velocity testing.
The small percentage of patients who have focal
neurological deficits consistent with central involve-
ment undergo MRI scanning with gadolinium con-
trast. The combination of clinical manifestations,
serology, and LP results will determine whether in-
travenous antibiotic therapy is indicated.
TREATMENT
Patients with neurological involvement in Lyme
disease are treated with intravenous antibiotics. The
antibiotics used, the duration of treatment, and the
doses remain controversial. We have found that two
weeks of intravenous treatment with 20 million units
of penicillin G is curative in Lyme meningo-
encephalitis. Ceftriaxone also has been used with
success, and other third-generation cephalosporins
probably will prove to be useful. As is the case in
Lyme arthritis, treatment of late parenchymal Lyme
disease is even more controversial. Fortunately, this
type of neurological involvement is unusual.
Encephalopathy generally responds to intravenous
antibiotics especially when a CSF pleocytosis is
present. Neuropathy also is antibiotic responsive. In
those few patients with focal demyelinating syn-
dromes associated with B. burgdorferi infection,
treatment with antibiotics has not been predictably
effective. The question always must be raised in
these patients whether the neurological disease is
due to active infection or an immune-mediated
phenomenon.
Patients who continue to be symptomatic with
fatigue, arthralgias, or myalgias after antibiotic
treatment are treated with nonsteroidal anti-inflam-
matory medications. These patients improve over
time and repeat intravenous antibiotics generally
are not necessary.
PROGNOSIS
The prognosis after adequate antibiotic treatment
of neurological involvement with Lyme disease is
excellent. Treatment “failures” are of two types: the
group of patients with definite Lyme meningo-
encephalitis who continue to have some symptoms
after treatment and these patients lose objective
signs of disease such as CSF pleocytosis and/or neu-
ropathy and they improve over months if treated
symptomatically with anti-inflammatory medi-
cations; and the group of patients who do not re-
spond to antibiotics because the diagnosis of Lyme
disease is inaccurate or because they have Lyme
disease in addition to some other neurological dis-
ease. Thus, some patients can have Lyme disease as
an incitement for multiple sclerosis and antibiotics
may not affect the course of their demyelination.
Some patients with severe neuropathic damage or
fixed lesions in the central nervous system (CNS)
may not improve back to baseline with treatment,
but this treatment outcome could hardly be con-
sidered a failure.
Future work will focus on improving our means of
diagnosis particularly in the CNS and optimizing
treatment regimens for patients. We need to know
more about the fate of the organism in the CNS; this
information most likely will come from animal
models. ■
REFERENCES
1. Reik L, Steere AC, Bartenhagen N, et al.: Neurologic
abnormalities of Lyme disease. Medicine 58:281-294, 1979.
2. Pachner AR, Steere AC: The triad of neurological
manifestations of Lyme disease. Neurology 35:47-53, 1985.
3. Stiernstedt GT, Skoldenberg BR, Vandvik B, et al.:
Chronic meningitis and Lyme disease in Sweden. Yale J
Biol Med 57:491-497, 1984.
4. Steere AC, Pachner AR, Malawista SE: Successful
treatment of neurologic abnormalities of Lyme disease
with high-dose intravenous penicillin. Ann Intern Med
99:767-772, 1983.
5. Pachner AR, Steere AC, Signal LH, et al.: Antigen-
specific proliferation of CSF lymphocytes in Lyme disease.
Neurology 35:1642-1643, 1985.
6. Pachner AR, Duray P, Steere AC: Central nervous
system manifestations of Lyme disease. Arch Neurol
46:790-795, 1989.
564
NEW JERSEY MEDICINE
Immunology of
Lyme Disease
LEONARD H. SIGAL, MD
The author discusses the immunology of Lyme disease in three categories:
immunologic changes (how the immune system is modified); im-
munopathogenetic mechanisms (how immune changes cause tissue dam-
age); and immunologic markers (how antigen-specific changes can be used
to confirm diagnosis).
The immunologic features of any infectious
disease that attract the interest of an im-
munologist fall into three broad categories:
immunologic changes; immunopathogenetic mech-
anisms; and immunologic markers. A discussion of
the immunology of Lyme disease can begin with
these categories. An understanding of the second
and third categories is crucial to making diagnostic
and therapeutic decisions about Lyme disease.
Immunologic Changes. Borrelia burgdorferi, the
causative agent of Lyme disease, is spread by Ixodes
Dr. Sigal is assistant professor, Departments of Medicine
and Molecular Genetics and Microbiology, UMDNJ-Rob-
ert Wood Johnson Medical School. Requests for reprints
may be addressed to Dr. Sigal, UMDNJ-Robert Wood
Johnson Medical School, 1 Robert Wood Johnson Place,
MEB 484, New Brunswick, NJ 08903-0019.
ticks and possibly by other hematophagous in-
sects.1,2 Tick saliva may play an important role in
transmission of the disease,3'5 and some have
proposed a second infectious agent may be trans-
mitted with B. burgdorferi ,6 Other Borrelia change
surface proteins readily,7,8 which may play a role in
avoidance of the immune response. It is known that
B. burgdorferi can change in culture, with loss of
plasmids,9 changes or loss of certain surface pro-
teins,10,11 and changes in morphology.12 Specific tissue
tropisms of B. burgdorferi have not been established
in humans, although the organism has been found
in the cerebrospinal fluid13 and brain,14,15 with ex-
tended survival within the reticuloendothelial sys-
tem and brain.16 These are in agreement with the
general affinity Borrelia has for neural tissue.17 In
animal models, the organism causing relapsing fever
VOL. 87— NUMBER 7 JULY 1990
567
can be found in spleen, eye, brain, and Kupffer
cells,17 whereas in the animal model of Lyme disease,
the organism is found within the spleen, kidney, eye,
heart, and urinary bladder.1819
The organism is capable of eliciting a broad range
of immunologic changes in the human host. Some
of this may be determined by the immunogenetic
type of the patient. HLA-DR2 was described as a
risk factor for late manifestations of Lyme disease,20
and for facial and other cranial neuropathies.21 Re-
cently, HLA-DR4 has been associated with chronic
arthritis22 and with both arthritis and radiculitis/
myeloradiculitis.21
Patients infected with B. burgdorferi experience
polyclonal B cell activation,23 which is to say that
the organism nonspecifically stimulates many dif-
ferent B cells in vivo, including B cells that make
antibodies not specific for the organism. The large
amount of IgM produced in some patients correlates
with progression to later manifestations of Lyme dis-
ease.24,26
Cryoglobulins26 and immune complexes27 are
found in serum and synovial fluid of patients with
Lyme arthritis. There is concentration of complexes,
as measured by Clq binding, in the synovial
fluid,27,28 where the complexes may be proinflam-
matory; the level of immune complexes in the sy-
novial fluid strongly correlates with the number of
polymorphonuclear cells in the fluid.27 Aggregates of
IgM and IgG are found within phagocytes isolated
from the fluid.28 Unlike rheumatoid arthritis, IgM
rheumatoid factor is not found in the serum of Lyme
arthritis, using the standard latex fixation tech-
nique,20,27,29 although, using the more sensitive
ELISA, IgM rheumatoid factor can be identified.30
Anti-nuclear antibodies, likewise, are absent in
Lyme disease.31
Cellular immune function also is modified in
Lyme disease. Early in the disease, lymphopenia is
found,24,32 the degree of which inversely correlates
with the total serum IgM. Anti-lymphocyte anti-
bodies have not been found.
Immunoregulation, as measured by the spon-
taneously active suppressor cell assay, is deficient
during acute disease and in those destined for later
disease.32 The addition of B. burgdorferi antigens to
normal peripheral blood mononuclear cells can in-
duce immunoregulatory changes in vitro. Using the
short-lived suppressor cell assay, differences be-
tween the synovial fluid and peripheral blood mono-
nuclear cell populations were documented; more
suppression of antigen-specific responses than of
mitogen-induced proliferation was found in the sy-
novial population, with the opposite the case in
blood.33 The ratio of phenotypic helper to suppressor
cells is normal in Lyme disease,26,34 but an increased
568
NEW JERSEY MEDICINE
ratio of inducers of help to inducers of suppression
has been found.35 Lyme disease synovial fluid con-
tains activated T lymphocytes of both the helper
and suppressor phenotype, with many more inducers
of help than of suppression present.35
Natural killer cell activity (NKCA) is decreased
in patients with active disease and returns to normal
with convalescence.34 As with immunoregulation,
the in vitro addition of B. burgdorferi antigens can
alter NKCA, as well.36
B. burgdorferi induces the production of inter-
leukin-1 (IL-1) by human mononuclear cells37-36 and
IL-1 is found in the synovial fluid of patients with
Lyme arthritis;39 the production of tumor necrosis
factor, another important monokine, may be stimu-
lated as well. These cytokines have broad im-
munologic activities, and can modify the function of
local tissue cells, like synoviocytes and fibroblasts.
Certain components of B. burgdorferi have chemo-
attractant activity for polymorphonuclear cells;40
same cells can be attracted to the site of inflamma-
tion by complement degradation products,41-42
liberated when the organism fixes complement.43
Thus, B. burgdorferi is capable of eliciting a
number of immunologic changes, systemic and local,
specific and nonspecific, that may be the cause of
tissue damage in Lyme disease.
Immunopathogenetic Mechanisms. B. burg-
dorferi has been growm from tissue taken from the
skin lesion, erythema chronicum migrans,13 from the
cerebrospinal fluid of patients with Lyme disease
meningitis/meningoencephalitis,13 and from the
joint fluid of a patient with Lyme arthritis.44 Thus,
there apparently is a live organism present at these
sites of inflammation. Using histopathologic tech-
niques, what appears to be B. burgdorferi has been
found in the heart of patients with Lyme disease
carditis45 and in the brain of a patient with tertiary
neuroborreliosis.46 The organism never has been seen
in peripheral nerve biopsies from patients with
Lyme-associated neuropathy.47 It is quite clear that
B. burgdorferi can cause widespread, occasionally
severe, tissue damage, perhaps even when the or-
ganism is not present locally, although the under-
lying mechanisms remain the subject of specu-
lation.47 These mechanisms can be divided into three
categories: local presence of live organism at the site
of inflammation; local presence of dead/effete or-
ganism at the site of inflammation; and organism-
derived products no longer present at the site of
inflammation.
Local presence of live organisms. If the organism
is alive and growing, in skin, joint, or brain, a local
inflammatory process can occur. B. burgdorferi can
fix complement, fragments of which will act as
chemotactic factors, attracting inflammatory cells.
Later, antibody to the organism will enhance both
complement fixation and phagocytosis, leading to
further inflammation. The local inflammation that
results then can cause tissue damage. In addition,
function of macrophages and T lymphocytes can be
modified locally by the organism. This can lead to
poor regulation of inflammation locally or possibly
to local tissue changes, e.g. sclerosis, due to modi-
fication of fibroblast function by locally produced
cytokines, or production of collagenase by syn-
oviocytes exposed to IL-1.48
Local presence of dead/effete organism. Many of
the same local changes might occur, even if the or-
ganism is dead or dying. Complement fixation, anti-
body binding, and local phagocyte function would
be the same whether the organism is alive or dead.
Cytokine production elicited by B. burgdorferi is
likewise not dependent on the viability of the or-
ganism. The antigens of B. burgdorferi are seemingly
poorly degraded. Such antigens, shed by disrupted
or dead organisms, could induce active inflamma-
tion, despite the absence of live microorganism.49-50
In situ immune complex formation could provide a
persisting pro-inflammatory focus.27 Finally, this
situation may provide the circumstances necessary
for the establishment of inflammation analogous to
that seen in the antigen-induced arthritis model. In
the animal model, an antigen is given intravenously
to sensitize the animal. Later inoculation of the
same antigen into the joint of this animal will lead
to inflammation of the joint.51 Later, intravenous
challenge with the same antigen results in a flare of
the arthritis in the original joint affected.52 The
liberation of B. burgdorferi- derived antigens from
foci of persistence of the antigen, e.g. the reticulo-
endothelial system [the site of residence of other
Borrelia 16 and Treponema pallidum 53], could induce
just such a flare of Lyme arthritis in a patient.47
Organism-derived products no longer present at
the site of inflammation. As in the peripheral neu-
ropathy of Lyme disease, there may be no evidence
of B. burgdorferi present, at the time of inflamma-
tion or previously. A possible explanation for the
genesis of tissue damage might be autoimmunity. In
at least two diseases, rheumatic fever and Chagas’
disease, a component of the microorganism involved
resembles a component of human tissue.54 In these
circumstances, the immune response to the micro-
organism then can recognize and damage the human
cross-reacting structure, a process known as
molecular mimicry. We have found that Lyme neu-
rologic patients have antibodies in their serum that
can bind human nerve, specifically the axonal por-
tion of nerve.54 The anti-axonal reactivity of these
sera can be absorbed out by incubation of the sera
with B. burgdorferi, but not other organisms, like
Staphylococcus aureus, Streptococcus pneumoniae,
Pseudomonas aeruginosa, or Proteus mirabilis. The
VOL. 87— NUMBER 7 JULY 1990
569
sera also bind to neuroblastoma cell lines derived
from human tumors. A single monoclonal antibody,
one of a number that binds to the organism’s
flagellin, also binds to axons and to the neuro-
blastoma cells; this monoclonal antibody immu-
noprecipitates a single protein from neuro-
blastoma cells, a protein of 67,000 daltons apparent
molecular weight. Thus, immunologic cross-reac-
tivity of the B. burgdorferi flagellin and this
previously undescribed protein may underlie the
peripheral neuropathy of Lyme disease. More work
is needed before this mechanism can be established
as active in Lyme disease.
Knowledge of the immunopathogenesis of Lyme
disease is important in interpreting responses to
antibiotics. Given the fact that dead or effete or-
ganisms can elicit a persisting inflammatory reac-
tion, it is no wonder that symptoms and signs of
Lyme disease may persist after therapy, for up to six
months or longer. If molecular mimicry is active in
the pathogenesis of tissue damage, responses may be
even slower, and may require immunomodulatory
therapy; this proposed mechanism of disease is not
established, so that any discussion of possible use of
such therapy is pure speculation.
Immunologic Markers. As described, two spe-
cific immunologic responses to B. burgdorferi have
been documented: humoral (antibody) responses
and cellular responses, and both can be used to help
support the diagnosis of Lyme disease.
Serologic techniques and their value in Lyme dis-
ease are covered elsewhere in this issue. Of note is
the fact that there is concentration of antigen-spe-
cific reactivity at the closed space site of inflamma-
tion, the meninges and the synovial cavity. Thus,
testing synovial fluid or cerebrospinal fluid and com-
paring with peripheral blood can be used to docu-
ment that the inflammation is due to B. burgdorferi
infection. Concentration of antibodies has been
documented in the cerebrospinal fluid of patients
with Lyme meningitis55 and these antibodies may
recognize B. burgdorferi antigens not bound by
serum antibodies.56 Concentration of antibodies in
the synovial fluid also has been documented in Lyme
arthritis. There is concentration of antigen-specific
reactive T lymphocytes in the cerebrospinal fluid of
patients with Lyme meningitis57 and in the synovial
fluid of arthritic patients.34 It is known that in
endemic areas, up to 5 to 10 percent of the popu-
lation may have antibodies that suggest prior ex-
posure to B. burgdorferi, but have no clinical
evidence of Lyme disease. Thus, concentration of
reactivity can be used to differentiate between an
individual who has Lyme arthritis or meningitis and
someone who has arthritis or meningitis due to
another cause and happens to have antibodies to B.
burgdorferi in his blood.
SUMMARY
B. burgdorferi is an organism capable of modifying
the immune response of its human hosts in a number
of specific and nonspecific ways. An understanding
of immune changes can help with diagnostic and
therapeutic decisions in Lyme disease. ■
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3. Hellerstrom S: Erythema chronicum migrans
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and acrodermatitis chronica atrophicans. Early and late
manifestations of Ixodes ricinus-borne Borrelia
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5. Ribeiro JMC, Makoul GT, Levine J, et al.: Anti-
hemostatic, anti-inflammatory and immunosuppressive
properties of the saliva of a tick, Ixodes dammini. J Exp
Med 161:332-344, 1985.
6. Neubert W: Zur Atiologie von erythema-migrans-
krankheit und Lyme erkraukung. Hautarzt 35:563-570,
1984.
7. Barbour AG, Tessier SL, Stoenner HG: Variable
major proteins of Borrelia hermsii. J Exp Med
156:1312-1324, 1982.
8. Barbour AG, Hayes SF: Biology of Borrelia species.
Microbiol Rev 50:381-400, 1986.
9. Herzer P, Wilske B, Preac-Mursic V, et al.: Lyme
arthritis: Clinical features, serological and radiographic
findings of cases in Germany. Klin Wochenschr
64:206-215, 1986.
10. Schwan TG, Burgdorfer W: Antigenic changes of
Borrelia burgdorferi as a result of in vitro cultivation. J
Infect Dis 156:852-853, 1987.
11. Wilske B, Preac-Mursic V, Schierz G, Busch V:
Immunochemical and immunological analysis of Euro-
pean Borrelia burgdorferi strains. Zbl Bakt Hyg A
263:92-102, 1986.
12. Hayes SF, Burgdorfer W, Barbour AG: Borrelia
burgdorferi: EM characterization of cloned and uncloned
strains. Ann NY Acad Sci 539:383-385, 1988.
13. Steere AC, Grodzicki RL, Kornblatt AN, et al.: The
spirochetal etiology of Lvme disease. N Engl J Med
308:733-740, 1983.'
14. MacDonald AB: Borrelia in the brains of patients
dying with dementia. JAMA 256:2195-2196, 1986.
15. MacDonald AB, Miranda JM: Concurrent
neocortical borreliosis and Alzheimer’s disease. Hum
Pathol 18:759-761, 1987.
16. Felsenfeld O: Borrelia, human relapsing fever, and
parasite-vector-host relationships. Bacteriol Rev 29:46-74,
1965.
17. Southern PM Jr, Sanford JP: Relapsing fever. A
clinical and microbiological review. Medicine 48:129-149,
1969.
18. Duray PH, Johnson RC: The histopathology of ex-
perimentally infected hamsters with the Lyme disease
spirochete, Borrelia burgdorferi. Proc Soc Exp Biol Med
570
NEW JERSEY MEDICINE
181:263-269, 1986.
19. Johnson RC, Kodner C, Russell M, Duray PH: Ex-
perimental infection of hamster with Borrelia burgdorferi.
Ann NY Acad Sci 539:258-263, 1988.
20. Steere AC, Gibofsky A, Patarroyo ME, et al.:
Chronic Lyme arthritis. Clinical and immunogenetic dif-
ferentiation from rheumatoid arthritis. Ann Intern Med
90:896-901, 1979.
21. Majsky A, Bojar M, Jirous J: Lyme disease and
HLA-DR antigens. Tissue Antigens 30:188-189, 1987.
22. Steere AC: Pathogenesis of Lyme arthritis. Ann NY
Acad Sci 539:87-92, 1988.
23. Sigal LH, Steere AC, Dwyer JM: In vivo and in vitro
B cell hyperactivity in Lyme disease. J Rheumol
15:648-654, 1988.
24. Shrestha M, Grodzicki RL, Steere AC: Diagnosing
early Lyme disease. Am J Med 78:235-240, 1985.
25. Sigal LH, Moffat CM, Steere AC, Dwyer JM:
Cellular immune findings in Lyme disease. Yale J Biol
Med 57:595-598, 1984.
26. Steere AC, Hardin JA, Ruddy S, et al.: Lyme
arthritis. Correlation of serum and cryoglobulin IgM with
activity and serum IgG with remission. Arthritis Rheum
22:471-483, 1979.
27. Hardin JA, Steere AC, Malawista SE: Immune
complexes and the evolution of Lyme arthritis. Dissemina-
tion and localization of abnormal Clq binding activity. N
Engl J Med 301:1358-1363, 1979.
28. Hardin JA, Steere AC, Malawista SE: The
pathogenesis of arthritis in Lyme disease: Humoral im-
mune responses and the role of intra-articular immune
complexes. Yale J Biol Med 57:589-593, 1984.
29. Steere AC, Malawista SE, Snydman DR, et al.:
Lyme arthritis. An epidemic of oligoarticular arthritis in
children and adults in three Connecticut communities.
Arthritis Rheum 20:7-17, 1977.
30. Kujala GA, Steere AC, Davis JS: IgM rheumatoid
factor in Lyme disease: Correlation with disease activity,
total serum IgM, and IgM antibody to Borrelia
burgdorferi. J Rheumatol 14:772-776, 1987.
31. Ryberg B, Hindfelt B, Nilsson B, et al.: Anti-neural
antibodies in Guillain-Barre syndrome and lymphocytic
meningoradiculitis (Bannwarth’s syndrome). Arch Neurol
41:1277-1281, 1984.
32. Moffat CM, Sigal LH, Steere AC, et al.: Cellular
immune findings in Lyme disease. Correlation with serum
IgM and disease activity. Am J Med 77:625-632, 1984.
33. Sigal LH, Steere AC, Freeman DH, Dwyer JM:
Proliferative responses of mononuclear cells in Lyme dis-
ease. Reactivity to Borrelia burgdorferi antigens is greater
in joint fluid than in blood. Arthritis Rheum 29:761-769,
1986.
34. Dattwyler RJ, Thomas JA, Benach JL, et al.:
Cellular immune responses in Lyme disease. Zentralblat
Bakteriol Mikrobiol Hyg 263:151-159, 1986.
35. Thomas JA, Lipschitz R, Golightly MG, Dattwyler
RJ: Immunoregulatory abnormalities in Borrelia
burgdorferi infection. Ann NY Acad Sci 539:431-433, 1988.
36. Golightly MG, Thomas JA, Dattwyler RJ, Volkman
D: Modulation of natural killer cells by Borrelia
burgdorferi. Ann NY Acad Sci 539:103-111, 1988.
37. Beck G, Habicht GS, Benach JL, et al.: A role for
interleukin-1 in the pathogenesis of Lyme disease. Zbl
Bakt Hyg A 263:133-136, 1986.
38. Habicht GS, Beck G, Benach JL, et al.: Lyme dis-
ease spirochetes induce human and murine interleukin 1
production. J Immunol 134:3147-3154, 1985.
39. Sigal LH, Steere AC, Dwyer JM: In vitro inter-
leukin-1 (IL-1) production by peripheral blood mono-
nuclear cells (PBMC) in Lyme disease. Arthritis Rheum
30:510, 1987.
40. Benach JL, Coleman JL, Garcia-Manco JD:
Biological activity of Borrelia burgdorferi antigens. Ann
NY Acad Sci 539:115-125, 1988.
41. Henriksson A, Link H, Cruz M, et al.: Im-
munoglobulin abnormalities in cerebrospinal fluid and
blood over the course of lymphocytic meningoradiculitis
(Bannwarth’s syndrome). Ann Neurol 20:337-345, 1986.
42. Henriksson A, Link H: Prolonged IgM response
within the central nervous system in lymphocytic menin-
goradiculitis (Bannwarth’s syndrome). N Engl J Med
313:1231, 1985.
43. Link H, Olsson T, Baig S, et al.: B-cell response on
the single cell level in CSF and peripheral blood (PB) over
the course of Lyme disease. Ann NY Acad Sci 539:389-392,
1988.
44. Schmidli J, Hunziker T, Moesli P, Schaad UB: Cul-
tivation of Borrelia burgdorferi from joint fluid three
months after treatment of facial palsy due to Lyme bor-
reliosis. J Infect Dis 158:905-906, 1988.
45. Reznick JW, Braunstein DB, Walsh RL, et al.:
Lyme carditis electrophysiologic and histopathologic
study. Am J Med 81:923-927, 1986.
46. Pachner AR: Spirochetal diseases of the CNS. Neu-
rol Clin 4:207-222, 1986.
47. Sigal LH: Lyme disease, immunologic mani-
festations and possible immunopathogenetic mechanisns.
Semin Arthritis Rheum 18:151-167, 1989.
48. Steere AC, Brinckerhoff CE, Miller DJ, et al.:
Elevated levels of collagenase and prostaglandin E2 from
synovium associated with erosion of cartilage and bone in
a patient with chronic Lyme arthritis. Arthritis Rheum
23:591-599, 1980.
49. Fumarola D, Munno J, Marcuccio C, Miragliotta G:
Endotoxin-like activity associated with Lyme disease Bor-
relia. Zbl Bakt Hyg A 263:142-145, 1986.
50. Coleman JL, Benach JL: Isolation of antigenic com-
ponents from the Lyme disease spirochete: Their role in
early diagnosis. J Infect Dis 155:756-765, 1987.
51. Cooke TDV, Sumi M, Maeda M: Deleterious inter-
actions of immune complexes in cartilage of experimental
immune arthritis. Clin Ortho 193:235-245, 1985.
52. van de Putte LBA, Lens JW, van den Berg WB,
Kruijsen MWM: Exacerbation of antigen-induced
arthritis after challenge with intravenous antigen. Im-
munology 49:161-167, 1983.
53. Fitzgerald TJ: The pathogenesis and immunology
of Treponema pallidum. Ann Rev Microbiol 35:29-54,
1981.
54. Sigal LH, Tatum AH: Lyme disease patient sera
contain IgM antibodies to Borrelia burgdorferi that cross-
react with neuronal antigens. Neurology 38:1439-1442,
1988.
55. Wilske B, Schierz G, Preac-Mursic V, et al.: In-
trathecal production of specific antibodies against Borrelia
burgdorferi in patients with lymphocytic meningo-
radiculitis (Bannwarth’s syndrome). J Infect Dis
153:304-314, 1986.
56. Murray N, Kristoferitsch G, Preac-Mursic G, et al.:
Specificity of CSF antibodies against components of Bor-
relia burgdorferi in patients with lymphocytic menin-
goradiculitis (Bannwarth’s syndrome). J Neurol
233:224-227, 1986.
57. Pachner AR, Steere AC, Sigal LH, et al.: Antigen-
specific proliferation of CSF lymphocytes in Lyme disease.
Neurology 35:1642-1644, 1985.
VOL. 87— NUMBER 7 JULY 1990
571
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572
NEW JERSEY MEDICINE
Lyme Disease in
Small Animals
BARRY A. LISSMAN, DVM
Dogs and cats can contract Lyme disease. The most common symptom in
cats is lameness. The most common symptoms in dogs include lameness ,
arthralgia, arthritis, lethargy, anorexia, fever, lymphadenopathy, generalized
pain, and neurologic, cardiac, and renal disease. Response to early treat-
ment with antibiotics is favorable.
Lyme disease was first reported in a dog from
a Long Island, New York, clinical setting in
1983.' Since then the disease has been re-
ported throughout most of the United States, with
endemic areas in New York, Connecticut, New Jer-
sey, Wisconsin, and Minnesota. Lyme disease is seen
in both cats and dogs.
CATS
Very few confirmed cases of Lyme disease actually
have been reported in cats; the reasons include: cats
are efficient groomers and may not allow the ticks
Dr. Lissman is affiliated with Sachem Animal Hospital,
Holbrook, NY. Requests for reprints may be addressed
to Dr. Lissman, Sachem Animal Hospital, 227 Union Av-
enue, Holbrook, NY 11741.
to stay on them long enough to transmit the or-
ganism; symptoms may not be as pronounced
clinically as they are in dogs; owners may miss early
signs; cats may have some inherent resistance to
borreliosis; and many cats remain indoors their en-
tire lives. The most frequent manifestation in cats
is lameness: cats appear to be lame more frequently
in the forelimbs, and respond favorably to early
treatment with amoxicillin or tetracyclines. Further
research is needed to identify the course of the dis-
ease in cats both clinically and serologically.
DOGS
Clinical manifestations of Lyme disease in dogs
can be divided into early and late (persistent) infec-
tions. In early infections, lameness is the most com-
VOL. 87— NUMBER 7 JULY 1990
573
mon finding. Arthralgia and arthritis most common-
ly are found in the carpal and stifle joints with swell-
ing of the carpal joints being pronounced in many
cases. Involvement may include one or more joints,
may be of short or long duration, and may show
single or intermittent periods of lameness.1 2 X-rays
usually reveal soft tissue swelling around the af-
fected joint, and may show effusion into the joint.
Dogs may be lethargic or anorexic, and fever is com-
mon, but not always seen, as is lymphadenopa-
thy.1 4'6 Erythema migrans (EM), the skin lesion com-
monly seen in early Lyme disease in humans, rarely
is seen in dogs. The lesion is a circular, expanding
rash with a pale area inside a darker border, similar
to a target. It usually is in the area of a recent tick
bite, and is seen in the areas with the least amount
of hair. It is unknown at this time if dogs commonly
have EM, or if it is undetected due to the hair coat.
Dogs with Lyme disease have been reported to
have generalized pain, especially in the cervical re-
in late or persistent infection with Lyme disease,
dogs can exhibit a chronic lameness and arthritis —
nonresponsive to antibiotics. They also may develop
chronic renal disease, cardiomyopathy, or chronic
neurological disease.
Treatment of Lyme disease in dogs is best ac-
complished early in the course of the disease with
antibiotics. Anti-inflammatory medications such as
aspirin may be useful for symptomatic relief in cases
involving lameness. Antibiotics effective against
Borrelia burgdorferi are tetracycline (10 mg/lb three
times a day), doxycycline (2 mg/lb once a day),
amoxicillin (5-10 mg/lb two times a day), amox-
icillin/clavulanic acid, and penicillin. The anti-
biotics usually are given for two to four weeks. Dogs
that are lame usually respond to treatment within
the first few days of treatment. In humans with
chronic infections, penicillin has been used in-
travenously. Ceftriaxone is administered in-
travenously to humans with neurological or chronic
Treatment of Lyme disease in dogs is best ac-
complished early in the course of the disease
with antibiotics. Anti-inflammatory medications,
such as aspirin, may be useful for symptomatic
relief in cases involving lameness.
gion. Radiographs usually do not display any lesions.
The neurological system also may be affected.3 Sei-
zures, aggression, change in behavior, and progres-
sive paralysis have been observed in dogs. The
cerebrospinal fluid (CSF) usually will show a
positive Lyme titer, and response to treatment is not
very favorable. Other reported symptoms have in-
cluded uveitis, hepatitis, renal failure including
glomerulonephritis, and cardiac disease including
conduction disturbances such as A-V block and
VPCs.7
Lyme disease as it is effective in crossing the blood-
brain barrier; however, little is known about its use
in dogs; its very high cost makes it impractical for
routine use.
Diagnosis of Lyme disease in dogs should be based
on clinical findings and positive serology. A history
of tick infestation or visits to endemic areas also
would be useful. Culture of the organism from blood,
synovial fluid, urine, or CSF is diagnostic; however,
difficulty in culturing Borrelia makes this very im-
practical. ■
REFERENCES
1. Lissman BA, Bosler EM, Camay H, et al.:
Spirochete-associated arthritis (Lyme disease) in a dog. J
Am Vet Med Assoc 185:219-220, 1984.
2. Magnarelli LA, Anderson JF, Schreier AB, et al.:
Clinical and serologic studies of canine borreliosis. J Am
Vet Med Assoc 191:1089-1094, 1987.
3. Bosler EM, Cohen DP, Schulze TL, et al.: Host
responses to Borrelia burgdorferi in dogs and horses. NY
Acad Sci 539:221-234, 1988.
4. Burgess EC: Exposure of Wisconsin dogs to the Lyme
disease spirochete. Lab Anim Sci 36:288-290, 1986.
5. Kornblatt AN, Urband PH, Steere AC: Arthritis
caused by Borrelia burgdorferi in dogs. J Am Vet Med
Assoc 186:960-964, 1985.
6. Magnarelli LA, Anderson JF, Kaufmann, AF, et al.:
Borreliosis in dogs from southern Connecticut. J Am Vet
Med Assoc 186:955-959, 1985.
7. Levy SA, Duray PH: Complete heart block in a dog
seropositive for Borrelia burgdorferi. J Vet Intern Med
2:138-144, 1988.
574
NEW JERSEY MEDICINE
Lyme Disease
in Large Animals
JOHN E. POST, DVM, PhD
Clinical signs of Lyme disease associated with musculoskeletal, nervous,
ocular, reproductive, hepatic, and renal involvement have been recognized
in seropositive horses, cows, and goats. Antibiotic therapy for large animals
generally is effective.
Clinical Lyme disease in large animals has
been recognized only in horses,1'5 cows,46-8
and goats.9 Informal reports from practicing
veterinarians indicate yearly increases in cases as
Lyme disease in animals is not reportable. The
clinical features and severity of disease varies and
many animals remain asymptomatic even though
infected with the causative organism, Borrelia
burgdorferi.
Most large animal cases have been limited to the
geographical areas where Ixodes dammini ticks are
common. Although these ticks are considered the
primary vector of Lyme disease, it now is suspected
Dr. Post is affiliated with the Department of Pathobiology,
University of Connecticut at Storrs. Requests for reprints
may be addressed to Dr. Post, University of Connecticut,
Storrs, CT 06269-3089.
that other modes of transmission may help dis-
seminate the disease. Borrelia spirochetes have been
demonstrated in other blood-sucking arthropods
such as Dermacentor variabilis and Amblyomma
americanum ticks, mosquitoes, horseflies, and deer
flies, but significant transmission by these is uncer-
tain.1011 More important in animals is the experimen-
tal evidence for oral infection. Mice12 and ducks13
have been infected by the oral administration of
cultured spirochetes. Organisms have been demon-
strated in the urine of infected mammals suggesting
that Lyme disease, like leptospirosis, may be spread
by urine contact.414 Organisms also have been dem-
onstrated in unpasteurized cows’ milk, making this
a possible vehicle for oral infection. Transplacental
transmission has been recognized in humans and is
suspected in animals. It is possible that blood trans-
VOL. 87— NUMBER 7 JULY 1990
575
fusions and contaminated hypodermic needles could
also transmit infection.
Signs similar to those in humans are being ob-
served in increasing numbers of B. burgdorferi-
seropositive horses, cattle, and goats. These clinical
manifestations as well as diagnosis and treatment
are discussed.
Horses. In Ixodes tick-infested areas, attached
nymph and adult ticks are being found on horses,
especially under the lower jaw, on the ventral chest
and abdomen, on the legs, in the mane, and on the
tail. At the site of attachment there is a crusty ex-
udate on the skin surface and a cellulitis-like swell-
ing that can grow to the size of a golf ball. The
results of a recent survey of equine clinicians in
Lyme-endemic areas in Connecticut and New York
described the most common manifestation in terms
of lassitude, depression, weakness, fatigue, ataxia,
paresis, incoordination, stiffness, recumbency, and
variable behavior and attitude changes. Low-grade
fever and anorexia may occur. Specific joint swelling
with pain, hyperthermia, and lameness, as seen in
humans, also is common. Uveitis has been observed
and renal and liver involvement may occur as
evidenced by elevated BUN, creatinine, and liver
enzyme values. One horse developed myocardial
conduction problems. Abortions have been observed
in a few seropositive mares, though cause and effect
have not been proved.
Since all of these signs can have other causes,
differential diagnosis is difficult. Absence of other
causes; a history of tick bites; a favorable response
to antibiotic therapy; and a positive laboratory test
for serum antibodies are helpful. However, serology
test results are not always diagnostic. Some horses,
like many humans, develop disease before antibody
levels have reached detectable levels. Also, many
seropositive horses are asymptomatic.
Treatment of all Lyme disease cases is based pri-
marily on antibiotic therapy to eliminate the infec-
tion. Based on human studies, the tetracyclines and
penicillins and, more recently, cephalosporins have
been most effective. To prevent relapses, these
should be administered for 10 to 14 days or longer
at regular dosage levels. The best therapy probably
is intravenous tetracycline, but this requires daily
veterinary attention. Oral tetracyclines are apt to
cause gastrointestinal problems. A long series of in-
tramuscular penicillin injections may cause con-
siderable pain and discomfort. Benzathine penicillin
administered intramuscularly every other day is
favored. Trimethoprim and sulfas have been re-
ported to be effective. Some horses, like some hu-
mans and dogs, may recover without treatment.
Response to tetracycline or penicillin generally is
good when treatment is started early. This helps
confirm a diagnosis. Chronic cases need to be treated
longer and may never recover from structural joint
changes. There is some evidence in other species
that antibiotic resistance patterns are developing,
thus, making the choice of an effective antibiotic
more difficult. Nonsteroidal anti-inflammatory
drugs, such as phenyl butazone, may be helpful as
supportive therapy.
A common question for veterinarians and owners
is whether or not to treat clinically normal
seropositive horses or other animals because such
animals may harbor latent infections. Until better
tests are available to determine latency, this ques-
tion cannot be answered. To eradicate suspected
infection in one seropositive horse, penicillin was
administered. Within two days, this clinically nor-
mal animal developed signs of Lyme disease
presumably as a result of a Jarisch-Herxheimer reac-
tion.17 Such a response suggests that this horse was
latently infected.
Cows. Identification of Lyme disease in cattle is
somewhat controversial. Using present-day tests for
serum antibodies, many cows test positive even
though located in areas free of Ixodes ticks. Also, in
tick-endemic areas, owners rarely find ticks on cows;
576
NEW JERSEY MEDICINE
however, cows may not be scrutinized as carefully
as dogs and horses. Spirochetes that appear to be
B. burgdorferi have been observed in bovine urine,
making this a suspected mode of transmission in the
absence of arthropod vectors.1 2 3 4 5 6 7 8 There also is the mat-
ter of disease expression. Some seropositive herds
have numerous clinically affected cows, but others
do not. There is, therefore, a suspicion by some that
finding B. burgdorferi serum antibodies is coinciden-
tal, and another agent, perhaps another closely re-
lated Borrelia, is involved in the herd problems
being observed.
The common clinical observations are lameness,
single or multiple swollen joints, arthritis, laminitis,
weight loss, and diminished milk production. A
warm hypersensitive hyperemic skin lesion resem-
bling the erythema migrans rash of humans or
simple sunburn has been seen on the udders of some
infected cows. Though not proved, abortions and
stillbirths in some herds are suspected of being
caused by B. burgdorferi; in these herds, problems
often begin after episodes of stress such as parturi-
tion.
Diagnosis depends on recognizing the clinical
signs described and ruling out other causes such as
traumatically induced carpal hygromas and chronic
hock swellings that have been seen for years in cows
stabled on concrete floors. As discussed for horses,
positive serology tests and recovery with antibiotic
therapy help confirm a diagnosis.
As for other species, the currently recommended
antibiotics for treatment are tetracyclines and peni-
cillins. Like horses, acute cases respond well and
chronic ones poorly, and some recover without treat-
ment. Cows showing only the udder lesions and
mildly swollen fetlock joints in one herd recovered
without therapy in two weeks. Similar cows treated
with oxytetracycline recovered in three to five days.
In some problem herds, seropositive cows are being
treated with penicillin during their dry period to
hopefully prevent clinical problems after parturi-
tion.
Goats. Lyme disease also is suspected in goats,
since clinical signs similar to those in cattle have
been seen in seropositive goats, and ticks have been
found. Differential diagnosis is especially difficult,
however, since CAE virus and mycoplasma also
cause arthritis.
LABORATORY TESTS AND INTERPRETATIONS
The currently available laboratory tests use either
IFA or ELISA procedures to measure antibody titers
as an indirect indicator of current or previous infec-
tion. Since there is no standardization between lab-
oratories, test values vary between different labora-
tories. Each laboratory must be consulted for ap-
propriate interpretation of their results. To detect
infected animals shedding organisms, tests for
spirochete proteins in urine have been developed
and are being tested. If effective, these will help
answer the frequent question of whether or not
seropositive animals are infected. Tests to detect
infection by dark field microscopy, culturing, or
special stains on body fluids and pathology tissues
are available at some laboratories but often are un-
successful. ■
REFERENCES
1. Burgess EC, Gillette D, Pickett JP: Arthritis and
panuveitis as manifestations of Borrelia burgdorferi infec-
tion in a Wisconsin pony. JAVMA 189:1340-1342, 1986.
2. Burgess EC, Mattison M: Encephalitis associated
with Borrelia burgdorferi in a horse. JAVMA
191:1457-1458, 1987.
3. Magnarelli LA, Anderson JF, Shaw E, et al.: Bor-
reliosis in equids in northeastern United States. Am J Vet
Res 49:359-362, 1988.
4. Burgess EC: Borrelia burgdorferi infection in Wis-
consin horses and cows. Ann NY Acad Sci 539:235-243,
1988.
5. Cohen D, Bosler EM, Bernard W, et ah:
Epidemiologic studies of Lyme disease in horses and their
public health significance. Ann NY Acad Sci 539:488,
1988.
6. Burgess EC, Gendron-Fitzpatrick A, Wright WO:
Arthritis and systemic disease caused by Borrelia
burgdorferi infection in a cow. JAVMA 191:1468-1470,
1987.
7. Post JE, Shaw EE, Wright SD: Suspected borreliosis
in cattle. Ann NY Acad Sci 539:488, 1988.
8. Rothwell JT, Christie BM, Williams C, et ah:
Suspected Lyme disease in a cow. Aust Vet J 66:296-298,
1989.
9. Post JE: Unpublished data.
10. Magnarelli LA, Anderson JF: Ticks and biting in-
sects infected with the etiologic agent of Lyme disease,
Borrelia burgdorferi. J Clin Microb 26:1482-1486, 1988.
11. Schulze TL, Bowen GS, Bosler EM, et ah:
Amblyomma americanum: A potential vector of Lyme
disease in New Jersey. Science 224:601-603, 1984.
12. Burgess EC, Patrican LA: Oral infection of Per-
omyscus maniculatus with Borrelia burgdorferi and subse-
quent transmission by Ixodes dammini. Am J Trop Med
Hyg 36:402-407, 1987.
13. Burgess EC: Experimental inoculation of mallard
ducks (Anas Platyrhynchos platyrhynchos) with Borrelia
burgdorferi. J Wildlife Dis 25:99-102, 1989.
14. Bosler EM, Schultz TL: The prevalence and signifi-
cance of Borrelia burgdorferi in the urine of feral reservoir
hosts. Zentralbl Bakteriol Parasitenkd Infektronskr Hyg
Abt 1 263:40-41, 1986.
15. Steere AC: Lyme disease. N Engl J Med
321:586-596, 1989.
16. Habicht GS, Beck G, Benach JL: Lyme disease. Sci
Am 257:78-83, 1987.
17. Robertson DHH, McMillan A, Young H: Jarisch-
Herxheimer Reaction. Baltimore, MD, University Park
Press, 1980.
VOL. 87— NUMBER 7 JULY 1990
577
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NEW JERSEY MEDICINE
Lyme Disease in
New Jersey
MARCIA J. GOLDOFT, MD, MPH
TERRY L. SCHULZE, PhD
WILLIAM E. PARKIN, DVM, DrPH
ROBERT A. GUNN, MD, MPH
Lyme disease case reports from 1984 through 1986 suggest different high-
risk groups and different disease severity than previously observed; children
appear disproportionately at risk. Early recognition of this under-reported
disease by physicians and patients is necessary for prompt treatment to
reduce complications.
Lyme disease is an infectious disease charac-
terized by a distinctive skin lesion, erythema
chronicum migrans (ECM); nonspecific sys-
temic symptoms; arthralgias and arthritis; neu-
rologic syndromes; and cardiac involvement.1 Symp-
toms occur in differing combinations and degrees of
severity. In New Jersey, the etiologic agent, the
spirochete Borrelia burgdorferi , is transmitted to hu-
Drs. Goldoft and Gunn are affiliated with the Centers for
Disease Control, Division of Field Services, Epidemiology
Program Office. Drs. Goldoft, Schulze, and Parkin are
affiliated with the New Jersey State Department of
Health, Division of Epidemiology, Communicable Dis-
ease Control Services. Requests for reprints may be ad-
dressed to Dr. Goldoft, New Jersey State Department of
Health, Division of Epidemiology, Communicable Dis-
ease Control Service, CN 360, Trenton, NJ 08625-0360.
mans principally by the deer tick (Ixodes dammini),
with the Lone-star tick serving as a secondary vec-
tor.2 Lyme disease was first reported in New Jersey
in 1978, 3 with subsequent retrospective identifi-
cation of additional cases from that year and 1979. 4
The disease now is considered endemic throughout
the state, with the highest incidence in the coastal
and central areas. Results of surveillance for Lyme
disease in New Jersey were reported previously for
117 cases occurring 1978 to 1982. 56 Data were not
collected in 1983. This report presents the descrip-
tive epidemiology of cases occurring in New Jersey
from 1984 through 1986.
METHODS
The New Jersey State Department of Health
(NJDOH) began receiving physician reports of Lyme
VOL. 87— NUMBER 7 JULY 1990
579
Table 1.
Clinical and serologic status of Lyme
disease cases, New Jersey, 1984-1986.
Case
Criteria
Cases
Clinical
Serologic
Number Percent
+
+
115
20
+
—
109
19
+
na
101
18
—
+
73
13
na
+
168
30
Total
566
100
na = Not available on submitted reporting forms.
disease in 1979 and established it as a reportable
illness in 1981. Surveillance from 1979 through 1982
used patient and physician interviews to obtain
clinical information. Data were not collected in 1983.
Beginning in 1984, case reports relied primarily on
the State Lyme Disease Surveillance Form, which
incorporated many of the criteria of the Centers for
Disease Control for Lyme disease.7 This form re-
quested both clinical information and epidemiologic
data relating to tick bites. In 1986, in addition to the
existing surveillance system, letters were sent to
physicians requesting full clinical reports in situ-
ations where the information available was insuffi-
cient to make a case determination. Serologic testing
for Lyme disease, offered by NJDOH, Division of
Public Health and Environmental Laboratories
since 1984, was available at the discretion of the
attending physicians.
Reports of cases of Lyme disease acquired in New
Table 2. Clinical presentation of Lyme disease cases, New Jersey, 1978-1982 and 1984-1986.
1978-1982
1984-1986
Symptom
Positive
Negative
Percent
Positive
Positive
Negative
Percent
Positive
ECM
107
5
96
298
52
85
Fever
59
24
71
220
130
63
Headache
50
24
68
188
140
57
Stiff neck
31
33
91
131
191
41
Headache/stiff neck
24
na
—
101
na
—
Myalgias
38
24
61
186
134
58
Malaise
40
21
66
193
100
66
Sore throat
13
27
33
64
201
24
Nausea/vomiting
21
28
43
79
189
29
Arthralgias
3
na
—
25
na
—
Arthritis
35
na
—
108
na
—
Cardiac
2
9
18
8
82
9
Neurologic
17
9
65
33
73
31
na = Not available on submitted reporting forms.
580
NEW JERSEY MEDICINE
Table 3. Serologic status and clinical manifestations of Lyme disease cases, New Jersey,
1984-1986.
Clinical Manifestation
Arthritis
Neurologic
Meningismus
ECM
Serology
Number
Percent
Number
Percent
Number
Percent
Number Percent
Positive
82
76
23
70
45
45
103
34
Negative
10
9
3
9
22
22
102
34
Unknown
16
15
7
21
34
34
94
31
Total
108
100
33
100
101
101*
299
99*
•Total not equal to 100% due to rounding.
Jersey from 1978 through 1986 were reviewed and
entered into a dBASE III file if they were clinical
cases meeting the definite or probable clinical case
definition or serologic cases as determined by a titer
of equal to or greater than 1:256 from NJDOH or an
outside laboratory. Standard reference populations
were obtained from the United States 1980 census
data.8
RESULTS
Diagnostic criteria. There were 566 reported
cases of Lyme disease acquired in New Jersey during
the three-year period 1984 through 1986 as shown in
Table 1. There were 325 cases that met the clinical
case definition; 152 cases had the definite diagnosis,
and 173 cases had the probable diagnosis. Only 20
percent of cases met both clinical and serologic
criteria for Lyme disease, and 48 percent of cases
lacked either clinical information or serologic test-
ing. Of all cases, 19 percent were seronegative while
meeting the clinical case definition, and 13 percent
did not meet the clinical case definition but were
seropositive.
Clinical manifestations. ECM was the most
commonly reported symptom. Overall, of 350
clinical records giving information from 1984
through 1986, 298 records (85 percent) had ECM
(Table 2). Atypical rashes described in 9 additional
records included macular or maculopapular rashes,
hives, generalized rashes including one mention of
palmar involvement, and a rash considered consis-
tent with erythema multiforme. Of patients with
ECM, 103 patients (34 percent) were seropositive,
102 patients (34 percent) were seronegative, and 94
patients (31 percent) did not have serologic tests.
Among cases with clinical information available
for analysis, nonspecific systemic symptoms such as
malaise, fever, and myalgias were commonly re-
ported in 1984 through 1986 as well as in the earlier
study. There were 101 cases reporting both headache
and stiff neck, and a negative lumbar puncture was
mentioned specifically 18 times as part of the medi-
cal evaluation.
Arthritis was reported in 108 cases and arthralgias
were reported in an additional 25 cases. The knee
joint was the most frequently reported site of
arthritis or arthralgias, although involvement of
ankles, shoulders, hips, elbows, hands, and wrists
also were reported. There were 36 reports of only
knee arthritis, 12 reports of other single joint type
involvement, and 29 reports of multiple joint in-
volvement. There were 3 reports in which temporo-
mandibular joint symptoms were reported, two re-
ports with no other joint involved.
Other complications not specifically asked on the
questionnaire were reported intermittently from
1984 through 1986. There were 33 persons with neu-
Table 4.
Tick bite exposure of Lyme disease
cases, New Jersey, 1984-1986.
Cases
Tick Bite Report
Number
Percent
Definite
175
31
Possible
130
23
No
37
7
Unknown
224
40
Total
566
101*
*Total not equal to 100% due to rounding.
VOL. 87— NUMBER 7 JULY 1990
581
Number of Cases
J FMAMJJASOND
(n = 497 cases) Month of Onset
Figure. Lyme disease in New Jersey by month of onset, 1984 to 1986.
rologic complications, including 22 cases of Bell’s
palsy. Adenopathy was reported for 12 cases. Cases
with arthritis, meningismus, or other neurologic
complication had higher rates of positive serology
than cases with ECM (Table 3).
Descriptive epidemiology. There were 566 cases
reported for the three-year period 1984 to 1986, with
a median of 189 cases per year and a range of 170
to 217. Although cases were reported from all
months, 73 percent of 485 cases had a date of onset
in May through August with a peak in June (Figure).
This peak corresponds temporally with the ac-
tivity of I. dcimmini nymphs. Cases with onset in the
other months probably are the result of exposure to
I. dammini adults. More than half of all cases re-
ported a definite or possible tick bite (Table 4).
For 227 cases, a specific county was reported as
the location of a tick bite in the three months prior
to the onset of symptoms. Sixteen of the 21 New
Jersey counties were reported as the location of a
tick bite for at least one Lyme disease case in the
three years. Hudson, Morris, Passaic, Sussex, and
Warren counties had no reports as the county of
exposure in that period. Lyme disease never has
been reported from Passaic and Warren counties.
Although the eastern coastal counties had been
predominant hyperendemic areas, central and west
central areas reported increased numbers of cases in
1986, particularly from Mercer county.
The male: female ratio of cases was approximately
one:one for the last 3 years, excluding nine cases
where laboratory reporting forms lacked sufficient
information to determine gender. Among age sub-
groups, males 10 to 19 years had about twice the
number of cases as females in that age group.
Among the 539 cases with gender and age infor-
mation, 10 percent (n = 52) occurred in persons 4
years old or younger, 27 percent (n = 142) occurred
in persons 9 years old or younger, and 44 percent (n
= 238) occurred in persons younger than 20 years old
(Table 5). Based on census denominators for the
state, the highest rate of Lyme disease infection was
for those 5 to 9 years old and the second highest rate
was for those 4 years or younger (Table 6). For per-
sons 10 to 19 years, the overall rate of reported cases
was 7.5/100,000, with males having a rate of 10.6 and
females having a rate of 4.3.
DISCUSSION
This study identified an increase in annual cases
of Lyme disease for 1984 through 1986, as compared
to 1978 through 1982. Prior to 1984, there were 117
case reports in New Jersey. Previously, the maxi-
mum number of cases reported for one year was 60
Lyme Disease. An inflammatory disorder,
first recognized in Lyme, Connecticut; typi-
cally it occurs during the summer months,
transmitted by the tick, Ixodes; first re-
ported in New Jersey in 1978.
582
NEW JERSEY MEDICINE
Table 5. Age distribution by sex of Lyme disease cases, New Jersey, 1984-1986.
Male Female Total
Age (Years)
Number
Percent
Number
Percent
Number
Percent
0-4
27
10
25
10
52
10
5-9
46
16
44
17
90
17
10-19
69
24
27
11
96
18
20-49
101
36
95
37
196
36
>49
39
14
55
21
94
17
Unknown
1
0
10
4
11
2
Total
283
100
256
100
539*
100
'Remaining cases lacked age information.
cases in 198256 while there were 179 cases in 1984,
170 cases in 1985, and 217 cases in 1986. This pattern
of increasing numbers of cases may represent either
a true increase in disease incidence or an artifact of
increased reporting. Anecdotal information from
county health officers and private laboratories in-
dicates a five- to tenfold under-reporting of cases,
suggesting that a true, and possibly underestimated,
increase in the cases of Lyme disease in the state has
occurred. A similar increase in the incidence of
Lyme disease reported in Connecticut9 supports the
observations from New Jersey.
The lack of concordance between clinical and
serologic findings noted in the surveillance system
may result from several factors. ECM may precede
the rise in titers, providing a clinical diagnosis, but
with negative serology. In contrast, an atypical
clinical course or a diagnosis after an extended
period may result in insufficient information to meet
the clinical case definition, although the infection is
present and the titers elevated. Seronegativity has
been reported for patients with objective symptoms
of Lyme disease responsive to parenteral antibiotic
treatment.10
Based on the 1984 through 1986 case reports, both
sexes appear equally at risk of contracting Lyme
disease for major age groups with the possible excep-
tion of adolescence. Connecticut results have simi-
larly shown an equal male:female ratio.911 Previous
studies in New Jersey had identified a male
preponderance in cases, 56 which may have resulted
due to a high rate of reporting from a military base
where the physicians were more aware of the disease
than the general medical community.
Children less than ten years old appear to be at
increased risk for contracting Lyme disease in New
Jersey, with rates of reported cases approximately
twice those for other age groups. An increased risk
for Lyme disease was noted for younger persons in
one study from Connecticut,9 although another
study from that state found the risks similar until
the fourth decade.11 If this risk actually exists, it may
reflect children’s greater participation in outdoor
recreational activities and lesser attention to prompt
tick removal.
Geographic distribution of cases occurring in 1978
through 1982 was primarily in southern and coastal
areas. A wider distribution occurred in 1984 through
1986 with a shift to include more westerly counties.
By extension, this expansion of disease reporting
may result from an increased geographic range for
the vector.
Table 6. Rates of Lyme disease cases by age
distribution, New Jersey, 1984-1986.
Age (Years)
Number
Rate/100,000
0-4
52
11.2
5-9
90
17.7
10-19
96
7.5
20-49
196
6.5
>49
94
4.5
Total
566
7.7
VOL. 87— NUMBER 7 JULY 1990
583
In earlier New Jersey studies of Lyme disease,
there was a greater prevalence of ECM. In previous
series, including a New Jersey study, severe clinical
manifestations were reported in relatively high fre-
quency with arthritis present in about half of the
patients, Bell’s palsy in 10 percent of the patients,
and meningitis in 10 to 25 percent of the
patients.1 2 3 4 5'6 7 8 * *'912'14
Lyme disease reports in New Jersey over the last
three years therefore suggest different risk groups
than had been found for earlier cases. An additional
finding was that fewer patients are being diagnosed
with chronic manifestations of illness as compared
to previous case series for the state. In particular,
arthritis was present in only a quarter of patients.
The observed reduction in New Jersey of more severe
clinical manifestations may result from earlier dis-
ease recognition by patients and physicians with
subsequent prompt and appropriate therapy.
Patient age, gender, geographic location, and even
history of tick bite may not immediately suggest
Lyme disease to the health care provider. The
diagnosis is best made on clinical grounds, which
may precede the titer elevation. Prompt antibiotic
therapy may abort antibody response.15 Physicians
must evoke clinical suspicion even in the absence of
a history of tick bite. Changing geographic distribu-
tion also must be considered since the disease may
be present in areas where it previously was rare.
Identification of these changes relies on case report-
ing from health care providers.
Diagnosis of Lyme disease emphasizes clinical fea-
tures, which is reflected in the preponderance of
cases reporting ECM. The serologic tests appear to
be specific,14 but sensitivity of the tests has been
questioned, particularly in early cases of Lyme dis-
ease.816 It has been suggested that a broader case
definition be used for the disease to include persons
with incomplete clinical symptoms whose illness can
be serologically confirmed.15
Continued surveillance through reporting forms is
encouraged in order to maintain databases able to
identify changes in risk groups for Lyme disease. In
mild cases, infected persons must be encouraged to
seek medical care before more severe symptoms de-
velop. In these cases, diagnosis should be made on
clinical grounds rather than serologic results, and
once the diagnosis is made, there should be prompt
initiation of antibiotic treatment. Increased public
awareness of Lyme disease is necessary to recognize
the disease early in its onset and seek timely medical
care.
SUMMARY
Lyme disease is a spirochetal infection endemic
throughout New Jersey. Case reports from 1984
through 1986 suggest different high-risk groups and
different disease severity than had been observed in
earlier cases in the state. Both sexes now appear
equally at risk, while younger age groups, particu-
larly children less than ten years old, appear to be
at increased risk. Mild disease is usual, although
classic rheumatologic and neurologic complications
can occur. Informal surveys suggest Lyme disease is
under-reported by a factor of five- to tenfold in New
Jersey. Early recognition by physician and patient
is necessary for prompt treatment to reduce com-
plications. ■
REFERENCES
1. Steere AC, Malawista SE, Hardin JA, et al . :
Erythema chronicum migrans and Lyme arthritis: The
enlarging clinical spectrum. Ann Intern Med 86:689-698,
1977.
2. Schulze TL, Bowen GS, Bosler EM, et al.: Amblyom-
ma americanum: A potential vector of Lyme disease in
New Jersey. Science 244:601-603, 1984.
3. Ward LC: A case of Lyme disease acquired in New
Jersey. J Med Soc NJ 78:469-470, 1981.
4. Slade JD, Lenz PP: Lyme disease in New Jersey: A
cluster of four cases and 11 sporadic cases. J Med Soc NJ
79:496-500, 1982.
5. Bowen GS, Griffin M, Haynes C, et al.: Clinical
manifestations and descriptive epidemiology of Lyme dis-
ease in New Jersey, 1978 to 1982. JAMA 251:2236-2240,
1984.
6. Bowen GS, Schulze TL, Parkin WL: Lyme disease
in New Jersey, 1978-1982. Yale J Bio Med 57:661-668,
1984.
7. Schmid GP, Horsley R, Steere AC, et al.:
Surveillance of Lyme disease in the United States, 1982.
J Infect Dis 151:1144-1149, 1985.
8. United States Department of Commerce, Bureau of
the Census: 1980 Census of Population, Volume 1, Chapter
B, Part 32. August 1982.
9. Steere AC, Taylor E, Wilson ML, et al.: Longitudinal
assessment of the clinical and epidemiological features of
Lyme disease in a defined population. J Infect Dis
154:295-300, 1986.
10. Dattwyler RJ, Volkman DJ, Luft BJ, et al.:
Seronegative Lyme disease. N Engl J Med 319:1441-1446,
1988.
11. Malawista SE, Steere AC: Lyme disease: Infectious
in origin, rheumatic in expression. Adu Intern Med
31:147-166, 1986.
12. Shrestha M, Grodzicki RL, Steere AC: Diagnosing
early Lyme disease. Am J Med 78:235-240, 1985.
13. Steere AC, Bartenhagen NH, Craft JE, et al.: The
early clinical manifestations of Lvme disease. Ann Intern
Med 99:76-82, 1983.
14. Mertz LE, Wobig GH, Duffy J, Katzmann JA:
Ticks, spirochetes, and new diagnostic tests for Lyme dis-
ease. Mayo Clin Proc 60:402-406, 1985.
15. Steere AC, Grodzicki RL, Kornblatt AN, et al.: The
spirochetal etiology of Lyme disease. N Engl J Med
308:733-742, 1983/
16. Hanrahan JP, Benach JL, Coleman JL, et al.: In-
cidence and cumulative frequency of endemic Lyme dis-
ease in a community. J Infect Dis 150:489-496, 1984.
584
NEW JERSEY MEDICINE
NOTEBOOK
^HUMDNJ NOTESMBi
The University of Medicine and
Dentistry of New Jersey (UMDNJ)
granted professional degrees and
certificates to more than 700 stu-
dents—285 doctor of medicine
degrees — at its 17th annual com-
mencement ceremony at the Gar-
den State Arts Center, Holmdel.
UMDNJ also awarded the Uni-
versity Medal to T. Edward
Hollander, New Jersey Chancellor
of Higher Education, and post-
humously, to Sammy Davis Jr,
the acclaimed entertainer noted
for his humanitarian endeavors.
Basil G. Bibby, DMD, PhD, dental
scientist and educator, was ac-
corded an honorary degree for his
pioneering work on fluoride.
UMDNJ’s Distinguished Alumnus
Award was given to Albert D. Pa-
cifico, MD, an internationally re-
nowned cardiac surgeon.
Scientists at UMDNJ-New Jer-
sey Medical School have shown for
the first time that the lives of
lethally irradiated mice can be
prolonged by injecting them with
blood from the human umbilical
cord. The researchers believe that
human umbilical cord blood ap-
parently supported the immune
system of the mice through the
critical period when they might
have died and also contained cells
that were able to generate new
blood.
This project’s outcome — getting
the recipient of one species to suc-
cessfully accept cord blood cells
from a different species — is
noteworthy because the immune
systems of the mouse and human
are not alike. Transplanted cells
are far more prone to being ac-
cepted if the recipient and the
donor are of the same species, the
research team said, because their
immune systems are the same. It
is the first time scientists have suc-
ceeded in growing human tissue in
mice whose immune systems were
intact prior to irradiation. Previ-
ously, human tissue had been
grown only in mice born without
immune systems. The researchers
believe that the success of this
project increases the odds that
human umbilical cord blood cells
could be used instead of bone mar-
row for patients with leukemia and
other blood diseases that may re-
quire a bone marrow transplant.
Nearly 80 percent of all Ameri-
cans will experience back problems
in their lifetime, but golfers drive
up those odds considerably, ac-
cording to surgeons at UMDNJ-
Robert Wood Johnson Medical
School. Orthopedic surgeons at the
school found that golfers put ex-
cessive stress on the lower back,
equalling up to eight times their
body weight each time they swing.
This stress, in addition to the
twisting and turning of the back
and torso, can lead to herniated
discs, spinal stress fractures, and a
variety of back-muscle strains.
According to a study of eight
golfers — four professionals and
four amateurs — the amateur golf-
ers tended to put more pressure on
their backs because of inconsistent
mechanics. Their total pressure
and lateral bending scores were 80
percent higher than professional
golfers while their torque readings
(twisting levels) were 50 percent
higher.
The study was led by Dr.
Timothy Hoser, clinical assistant
professor of surgery.
Researchers at UMDNJ-Robert
Wood Johnson Medical School
have found a new use for a syn-
thetic collagen originally de-
veloped to heal skin ulcers. The
collagen, protein made from
purified cowhide skin, may help re-
pair the most commonly damaged
part of the knee — the torn anterior
cruciate ligament. The researchers
say the collagen ligament not only
lends support to the injured liga-
ment but also promotes the forma-
tion of new ligament tissue. The
result, it is hoped, will be a strong-
er, healthier knee. The collagen
was designed several years ago by
Dr. Fred Silver, associate professor
of pathology at UMDNJ-Robert
Wood Johnson Medical School, as
skin replacement for patients suf-
fering skin loss. Dr. Michael Dunn,
assistant professor of surgery, is
leading the ligament research.
A study of automobile drivers in
two New Jersey counties will help
to determine whether an intensive
information campaign can increase
the use of seatbelts. The one-year
study is sponsored by the New Jer-
sey Division of Highway Traffic
Safety. The data will be analyzed
and presented by the Level I New
Jersey State Trauma Center at
UMDNJ-University Hospital,
Newark. Public employees in the
two counties will be observed
without their knowledge to de-
termine how many of them wear
seatbelts. The Division of Highway
Traffic Safety then will blitz one
county with an extensive public-
awareness campaign and do
nothing in the other. To preserve
the integrity of the study, the two
counties will not be identified.
VOL. 87— NUMBER 7 JULY 1990
585
Employees will continue to be
surveyed to determine if seatbelt
use increases or decreases in either
county as the result of the educa-
tional campaign. □ Stanley S.
Bergen, Jr, MD
BHMSNJ AUXILIARY Hi
Dr. and Mrs. Richard Lorber, and their two children, Brian and Jennifer, at the
Medical Society of New Jersey Annual Meeting.
The following address was pre-
sented by Mrs. Jane Lorber at her
inauguration as MSNJ Auxiliary
president:
Have you noticed that women
today do not like to be “Auxiliary”
anything? We prefer to be counted
as persons in our own right rather
than as props for our husbands. I
believe that is what this organiza-
tion allows us to be — persons in our
own right. We are married to phy-
sicians but we are more than just
wives. Many of us are working
women with career responsibili-
ties; and most of us are mothers
with maternal responsibilities. We
know about the lonely nights, the
cold dinners, and the heavy burden
of feeling like both mother and
father to our children. We know
that medicine is a jealous mistress
and our husbands are enthralled in
a lifelong romance. So we must,
first of all, accept that. Then, we
must fashion lives for ourselves
around that central fact.
If we are realistic, we should be
excited by the challenge. Our hus-
bands, by their very nature, are
smarter than average. The fact
that we are married to these
outstanding individuals says much
about us. We are no dummies, or
we would not be here. We have
everything it takes to stand on our
own two feet and command re-
spect. We are more than tea
parties, fur coats, and jewelry. Let
us reach out to one another and to
the world around us and extend
our considerable talents to make
our own special mark.
Reaching out — that is what I
would like us to do. We have to
help others as only we can. We
need to reach out to our com-
munities and address the problems
of drugs, adolescence, child safety,
and health education. Our fall
seminar will focus on AIDS educa-
tion as well as the effects of smok-
ing. Again, we will invite educators
and high school students. Ad-
ditionally, we will urge our county
auxiliaries to continue providing
health career scholarships.
We also must reach out to our
own — to the widows of physicians
who do not know where to turn for
advice on how to close an office,
sell a practice, or refer patients; to
the families of impaired physicians
shocked and stunned by a burden
too heavy to be borne; to impaired
spouses who have lost their way;
and to the families of physicians
being sued for malpractice who
must deal with the anger and frus-
tration such a devasting event can
bring. We must let them know we
are here for whatever they need.
And, we must reach out to the
young wives of physicians new in
residency or new in practice who
are unsure of themselves and often
involved with children or looking
for jobs in a new community. If we
can help these women, we will be
promoting the long-term growth of
this organization. If all we do is call
on the phone and say “join us” or
invite them to a get-together, we
are not truly reaching out. We
must call and say “I know it is
tough because I have been where
you are and we, the Auxiliary,
want to help. What do you need?”
We also must support and en-
courage the efforts of organized
medicine. The physicians who par-
ticipate at the county and state
levels often need to learn new skills
of communication and leadership
586
NEW JERSEY MEDICINE
styles. In the coming year, we hope
to set up a joint leadership training
session for members of MSNJ and
the Auxiliary to develop the skills
we need to preserve the best medi-
cal system in the world today.
Let us not forget that the honor
and dignity of the medical pro-
fession are under constant attack
by the media and by members of
the state and federal governments.
For several years, the Auxiliary has
played an active role in providing
useful information to such entities.
This year, we hope to inaugurate
the first “joint legislative day” in
Trenton, with participation by
members of both the Society and
Auxiliary. This is hard work. It can
be done only by those with sure
knowledge of the issues and a thick
skin. It can be done only by those
of us who are willing to get out in
public and fight for the medical
profession. It can only be done by
dedicated Auxiliary members and
here we are — ready to reach out to
the community, to the legislature,
and to each other.
Let us pledge ourselves right
now to work for the common good
and to command the respect we
deserve as women. Is it difficult?
Yes. Is it challenging? Yes. Can we
do it? Absolutely! I reach out to
each and every one of you today —
join me in this challenge. Together
we can make this world a better
place. □ Jane Lorber
■ INTEREST CHARGES*
The following is the opinion of
the Judicial Council concerning
interest charges. This opinion of-
ficially was adopted on March 8,
1989.
A physician who has experienced
problems with delinquent accounts
may properly choose to add
interest or other reasonable billing
charges to delinquent accounts.
The patient must be notified in ad-
vance of the interest or service
charges by means of posting a no-
tice in the waiting room, the dis-
tribution of leaflets in the office,
and appropriate notations on bill-
ing statements. The physician
must comply with state law which
limits interest to the rate approved
by the state supreme court. The
approved rate changes annually.
The rate until November 1990 is
8 percent. Physicians are en-
couraged to make exceptions in
hardship cases.
The Council does not believe it
is appropriate to add attorney fees,
court costs, or collection costs to
the amount owed. If, however,
costs and fees are added by court
determination, it is appropriate to
collect them. □
^■PLACEMENT FILE i*i
The following physicians have
written to the Executive Offices of
MSNJ seeking information on
practice opportunities in New Jer-
sey. The information listed below
has been supplied by the physi-
cians. If you are interested in any
further information concerning
these physicians, we suggest you
make inquiries directly to them.
INTERNAL MEDICINE
Marc Kesselhaut, MD, 1 Rustic Ridge,
C16, Little Falls, NJ 07424. St.
George’s (Grenada) 1986. Board eligi-
ble. Solo or partnership in Mercer,
Somerset, Burlington, Hunterdon, or
Middlesex counties. Available Sep-
tember 1990.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
Medical College (India) 1980. Board
certified. Board eligible (GASTRO).
Group, partnership, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital-based. Available
July 1990.
PATHOLOGY
Judith Vople, MD, 106 Orlando Blvd.,
Toms River, NJ 08757. UMDNJ 1985.
Board eligible. Group or hospital-
based. Available July 1990.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Wood-
side Ave., Trenton, NJ 08618. Rutgers
1980. Board certified. Part time or full
time. Available.
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
VOL. 87— NUMBER 7 JULY 1990
587
Bellevue Hospital Center
Emergency Services
FIVE-DAY
EMERGENCY
MEDICINE BOARD
REVIEW COURSE
MONDAY-FRIDAY OCTOBER 8-12, 1990
An intensive, five-day course providing:
• Concentrated review and update of Emergency
Medicine topics
• Analysis of relevant articles from the past six years of
Emergency Medicine literature
• Interaction regarding clinical controversies in
management techniques
• Sessions in written test-taking, and oral problem
solving in ED medicine
• Group sessions to assist participants with Oral Board
preparation
• Review of sample multiple choice questions with
emphasis on test taking techniques
• Special opportunities for 1 on 1 sessions with Board
certified faculty to be provided on an ongoing basis
throughout the course
TUITION: $700
ACCREDITATION: 39AMA Category I credit hours/
ACEP credit pending
For further information: NYU Post-Graduate Medical School,
550 First Avenue, New York, NY 10016 (212) 340-5295 NJ7A
Acupuncture & Electro-Therapeutics
in Clinical Practice
New York State Boards of Medicine & Dentistry
25 -hour accredited seminar & workshop on latest theories
and techniques of manual & electro-acupuncture, TENS &
simple non-invasive diagnostic methods (including
cardio-vascular, neuromuscular, central nervous systems &
"Bi-Digital O-Ring Test”), applicable towards 300-hour
requirement for certification to practice acupuncture, will be
given periodically for licensed clinicians (with or without
prior training) on 3-day weekends (Fri-Sun) of July
13-15, Sept. 21-23, and Dec. 14-16, 1990, at Milford
Plaza Hotel, 45th St. & 8th Ave., New York City.
The 6th Annual International Symposium on
Acupuncture & Electro-Therapeutics will be held at
Columbia University, School of International Affairs, 420
W. 118th St., N.Y. City, during October 25-28, 1990.
These meetings are co-sponsored by the International
College of Acupuncture & Electro-Therapeutics & its official
journal. Acupuncture & Electro-Therapeutics Research. The
International Journal ^published by Pergamon Press &
indexed in 15 major indexing periodicals, including Index
Medicus), Heart Disease Res. Foundn, N Y Pain Center of
Long Island College Hospital (a teaching hospital of
SUNY-Health Science Center at Brooklyn); Electrical
Engineering Dept., Manhattan College; Nordic Medical
Acupuncture Society (Scandinavia); Schmerz Therapeutische
Kolloquium (West Germany); Japan Bi-Digital O-Ring Test
Assn; etc. The meetings are also eligible for AMA CME Cat.
I credit (about 40 credit-hours for the Symposium).
For information on meetings or submission or presen-
tation of papers, contact Symposium Chairman, Prof.
Y. Omura, M.D., Sc.D., 800 Riverside Drive (8-1) New
York, NY 10032 Tel: (212) 781-6262 (10am to 10pm 7
days a week) or (212) 928-0658, Co-chairman, Prof.
A.W. Cook, MD, (516) 877-1821, or Bro. Michael
Losco (212) 920-0162.
PRACTICE MEDICINE. NOT PAPERWORK.
In Navy Medicine the
emphasis is on patients,
not paperwork.
As a Navy doctor,
you step into an active
and challenging group
practice. You work with
state-of-the-art equip-
ment and the best
facilities available.
Highly trained
physician’s assistants,
hospital corpsmen,
nurses and hospital
administrators not only
provide medical support, they attend to almost all the paperwork. As a result, you’re
free to make medical decisions based solely on the needs of your patients.
Along with your professional development, you'll enjoy the lifestyle and fringe
benefits of a Navy officer. Beginning salaries are comparable with hospital staff
positions for most specialists.
I o learn more about the Navy’s practice made perfect, send your curriculum
vitae or call:
In New Jersey and PA 1-800-822-0195
BE THE DOCTOR YOU WANT TO BE.
IN THE NAVY.
588
NEW JERSEY MEDICINE
CONTINUING EDUCATION
ANESTHESIOLOGY
September
18 Anesthesiology Meeting
6-9 P.M.— Ramada Inn, Clark
( New Jersey State Society
of Anesthesiologists)
22 Tenth Annual Clinical
Anesthesia Meeting
8 A.M.-4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
INFECTIOUS DISEASE
August
1 Counseling and Testing for HIV
Infection
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ and NJDOH)
15 Clinical Management of HIV
Infection
1- 2 P.M. — VA Medical Center,
Lyons
(AMNJ and NJDOH)
21 Clinical Management of HIV
Infection
12 Noon-1 P.M. — Englewood
Hospital, Englewood
(AMNJ and NJDOH)
21 Clinical Management of HIV
Infection
7:30-8:30 A.M. — Mercer Medical
Center, Trenton
(AMNJ and NJDOH)
21 AIDS Training and Resource
Program
8-9 A.M. — Wallkill Valley
Hospital and Health Center,
Sussex
(AMNJ and NJDOH)
23 Counseling and Testing for HIV
Infection
12 Noon-1 P.M. — Englewood
Hospital, Englewood
(AMNJ and NJDOH)
September
5 AIDS Training and Resource
Program for Hospital Health
Educators
2- 3 P.M. — John E. Runnells
Hospital, Berkeley Heights
(AMNJ and NJDOH)
14 AIDS Training and Resource
Program for Hospital Health
Educators
9:30-11:30 A.M. — New Lisbon
Developmental Center, New
Lisbon
(AMNJ and NJDOH)
17 Counseling and Testing for HIV
Infection
10-11 A.M. — Hackensack Medical
Center, Hackensack
(AMNJ and NJDOH)
20 Using Counseling and Testing
as a Management Strategy for
the HIV Infected Individual
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
24 Clinical Management of HIV
Infection
10-11 A.M. — Hackensack Medical
Center, Hackensack
(AMNJ and NJDOH)
26 AIDS Training and Resource
Program for Hospital Health
Educators
9-10 A.M. — Hackensack Medical
Center, Hackensack
(AMNJ and NJDOH)
MEDICINE
August
7 Grand Rounds
14 8:30-10 A.M. — Elizabeth General
21 Medical Center, Elizabeth
28 (Elizabeth General
Medical Center)
7 Topics in Public Health
12:15-1:30 P.M.— John Fitch
Plaza, Trenton
(NJDOH and AMNJ)
14 Head Trauma in Children
9:30-10:30 A.M. — Shore Memorial
Hospital, Somers Point
( Shore Memorial Hospital)
16 New Treatment Modalities and
Implications for the Future in
Diabetes
7:30-8:30 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
23 Newer Cardiac Drugs and Local
Anesthetic Interactions
12 Noon-1 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
September
4 Grand Rounds
11 8:30-10 A.M. — Elizabeth General
18 Medical Center, Elizabeth
25 (Elizabeth General
Medical Center)
7 Modern Surgical Treatment of
Peptic Ulcer Disease
7:30-8:30 A.M. — Freehold Area
Hospital, Freehold
(AMNJ)
10 Diabetes in Pregnancy
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ)
10 Hepatitis
7- 8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
11 Topics in Public Health
25 12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(AMNJ)
12 New Practice Program
8 A.M. -3:30 P.M.— MSNJ, Two
Princess Road, Lawrenceville
(MIIENJ)
27 Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
8- 9 P.M. — Freehold
Area Hospital,
Freehold
(AMNJ)
ONCOLOGY
August
9 Tumor Board
9-10 A.M. — Irvington General
Hospital, Irvington
(Irvington General Hospital)
10 Tumor Board Meeting
11 A.M. -12 Noon — Wallkill Valley
Hospital Center, Sussex
(Wallkill Valley
Hospital Center)
13 Tumor Board Case Presentation
9-10 A.M. — Irvington General
Hospital, Irvington
(Irvington General Hospital)
VOL. 87— NUMBER 7 JULY 1990
589
Magnetic Resonance Imaging
M Rimaging of Morristown
355 Madison Avenue
Morristown, NJ 07960
Patient Scheduling
(201) 829-0308
MRImaging of Union
2770 Morris Avenue
Union, NJ 07083
Patient Scheduling
(201) 686-2450
w
Patient Scheduling
(609) 983-5599
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MRImaging of South Jersey
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TO OBTAIN MORE INFORMATION ABOUT MAGNETIC RESONANCE (MRI)
Name _
Address
Phone
Send Me:
Mail Requests to:
MRI Case Study
Information
Scheduling
Information
NMR of America
Attn: Physician Outreach Dept.
355 Madison Avenue
Morristown, NJ 07960
Other (Specify) Or Call:
(201) 539-1082
590
NEW JERSEY MEDICINE
PSYCHIATRY
30
August
2 NMR: Application to Affective
Illness and Lithium
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
7 Psychiatry Grand Rounds
14 8:30-10 A. M.— Elizabeth General
21 Medical Center, Elizabeth
28 (Elizabeth General
Medical Center)
9 Foods, Fats, and Fraud Diets
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
16 Food and Fitness Habits
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
Brain Imaging and the
Electroconvulsive Patient
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
September
4 Psychiatry Grand Rounds
11 8:30-10 A. M. — Elizabeth General
18 Medical Center, Elizabeth
25 (Elizabeth General
Medical Center)
6 Computerized EEGs — Role in
Clinic Psychiatry
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
13 HIV Spectrum Disorder:
Counseling, Psychotherapy, and
Pharmacotherapy
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
20 Premenstrual Syndrome:
Diagnosis and Treatment
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
26 Velvet and Armour
All day — Carrier Foundation,
Belle Mead
( Carrier Foundation)
RADIOLOGY
September
13 Monthly Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of
New Jersey)
SPECIAL ISSUE
Lyme Disease In New Jersey
Lyme Disease
in New Jersey
Prevention and Control
of Lyme Disease
Lyme Disease and its
Psychological Impact
Lyme Disease
During Pregnancy
Neurological Manifestations
of Lyme Disease
Animals and Lyme
Disease
Immunology of
Lyme Disease
Clinical Manifestations
of Lyme Disease
Additional copies will be available for $6.50
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
VOL. 87— NUMBER 7 JULY 1990
591
Your own
medicine
The Exchange is the only company
providing professional liability insurance that is
endorsed and sponsored by the Medical Society
of New Jersey.
The Exchange was founded in 1976 by the
Society itself because New Jersey physicians
urgently needed a secure, stable professional
liability program. The commercial carriers had
abandoned the State. The Exchange is
governed by its insured physicians because a
doctor-owned company can best take care of
medical professionals’ needs.
That’s why the Exchange’s membership
includes more than 7,500 practicing physicians
and surgeons in New Jersey . . . a taste of their
own medicine. /=j=V Medical Inter-Insurance
Exchange of New Jersey
2 PRINCESS ROAD, LAWRENCEVILLE. NEW JERSEY 08648
800-257-6288 609-896-2404
592
NEW JERSEY MEDICINE
l _ .
MEMORIAM
John W. Bromley. A former
member of our Passaic County
component, John Wickliffe Brom-
ley, MD, died April 1, 1990, at the
age of 62. Born in Michigan, Dr.
Bromley earned his medical degree
from Cornell University Medical
College, New York, in 1952. He
served an internship at Lenox Hill
Hospital, New York, and an or-
thopedic residency at two New
York hospitals, Lenox Hill Hospi-
tal and New York University
Bellevue Hospital. He received his
New Jersey license in 1959 and his
California license the previous
year. An orthopedic surgeon, Dr.
Bromley had a private practice in
Paterson, and was affiliated with
St. Joseph’s Hospital and Medical
Center and Wayne General Hospi-
tal. Dr. Bromley was a diplomate
of the American Board of Ortho-
pedic Surgery, a senior member of
the International Society for the
Study of the Lumbar Spine, a fel-
low in both the New York and New
Jersey Academies of Medicine, and
a member of the New Jersey Or-
thopedic Society, and of the East-
ern Orthopedic Society. Dr.
Bromley served in the United
States Army from 1953 to 1955,
with a terminal rank of first
lieutenant.
Harold Davis. Born January 1,
1911, in New York City, general
practitioner Harold Davis, MD,
died April 28, 1990, at the age of
79. Dr. Davis earned his medical
degree from Dalhousie University
Faculty of Medicine, Canada, in
1937. After serving in the armed
services from 1942 to 1945 as cap-
tain, Dr. Davis received his New
Jersey medical license in 1945 and
had a private practice in Bergen-
field until his retirement in 1985.
Dr. Davis was a member of our
Bergen County component and of
the American Medical Association.
Ralph A. Eckhardt. Born on
June 8, 1899, in Rochester, New
York, Ralph A. Eckhardt, MD, re-
cently died. In 1925, Dr. Eckhardt
received his medical degree from
Cornell University Medical Col-
lege, New York. Two years later he
earned his New Jersey medical
license. Dr. Eckhardt had a gen-
eral private practice in Madison
and was affiliated with Morristown
Memorial Hospital and with the
former All Souls Hospital, Mor-
ristown. He was a member of the
American Medical Association and
of our Morris County component.
Bernard Friedenthal. A retired
general surgeon, Bernard Frieden-
thal, MD, died at the age of 79. Dr.
Friedenthal was born in New York
City on April 3, 1911, and earned
his medical degree from the Uni-
versity of Berne, Switzerland, in
1936. He served his internship and
residency at the former Middlesex
General Hospital, New Brunswick,
and at the former Fitkin Memorial
Hospital, Neptune, respectively.
After receiving his New Jersey
medical license, Dr. Friedenthal
had a general practice in the New
Brunswick area for many years. He
was affiliated with two New Bruns-
wick hospitals: the former Middle-
sex General Hospital and St.
Peter’s Medical Center. During
World War II, he served in the
United States Medical Corps
achieving the rank of lieutenant
colonel. Dr. Friedenthal was a
member of our Middlesex County
component and of the American
Medical Association, and a fellow
of the American Association for the
Advancement of Science and of the
International College of Surgeons.
Jutta A. Gabe. Cherry Hill resi-
dent, Jutta Anna Gabe, MD, died
on March 5, 1990. Born in Ger-
many in 1924, Dr. Gabe received
her medical degree from the Uni-
versity of Marburg and Goet-
tingen, Germany, in 1953. She
served her internship at Cooper
Hospital, Camden, and her resi-
dency at Graduate Hospital of the
University of Pennsylvania School
of Medicine, Philadelphia. In ad-
dition, she served a fellowship at
the Medical College of Penn-
sylvania, Philadelphia. In 1959,
she was awarded her New Jersey
medical license. An anesthesiol-
ogist at Cooper Hospital, Dr. Gabe
was a member of our Camden
County component and of the
American Medical Association.
Gregory Jawny. At the age of
90, Gregory Jawny, MD, died on
April 18, 1990. Dr. Jawny was born
in 1900 and received his medical
degree from the University of Vien-
na, Austria, in 1926. Dr. Jawny
earned his New Jersey medical
license in 1955. Retired for many
years from the active practice of
internal medicine, Dr. Jawny had
a general private practice in
Rutherford and then Jersey City
and was affiliated with the former
Fairmount Hospital, Jersey City,
and Jersey City Medical Center.
Dr. Jawny was a member of our
Hudson County component and of
the American Medical Association.
VOL. 87— NUMBER 7 JULY 1990
593
Martin A. Quirk. Past-presi-
dent of our Sussex County compo-
nent in 1930, Martin Aloysius
Quirk, MD, died recently. Born in
Long Branch on September 16,
1901, he received his medical
degree from the University of
Pennsylvania School of Medicine,
Philadelphia, in 1927 and his New
Jersey medical license in 1928. Dr.
Quirk served his internship at The
Mountainside Hospital, Mont-
clair. Before retiring from active
practice, Dr. Quirk had a private
pediatric practice in Newton and
then relocated to Red Bank. He
was affiliated with several area
hospitals: Monmouth Medical
Center, Long Branch; Riverview
Medical Center, Red Bank; and
Jersey Shore Medical Center, Nep-
tune. Dr. Quirk was a fellow of the
American Academy of Pediatrics,
a diplomate of American Board of
Pediatrics, and a member of our
Sussex County and Monmouth
County components. In addition,
he served in the United States
military as commander from 1942
to 1945.
Bhatrahally K. Venkatesh.
Born in India on April 6, 1931,
Bhatrahally Krishnarao Venka-
tesh, MD, died on March 14, 1990.
Dr. Venkatesh received his medi-
cal degree from the University of
Mysore Medical School, India, in
1953. Prior to coming to the United
States, Dr. Venkatesh practiced
medicine in his native country. He
served his residency at several New
York hospitals: Memorial Hospital
for Cancer and Allied Diseases,
Metropolitan Hospital Center, and
the former Francis Delafield Hos-
pital. Dr. Venkatesh received his
New York medical license in 1971
and his New Jersey medical license
in 1973. Dr. Venkatesh was a radi-
ologist at Wayne General Hospital.
Dr. Venkatesh was a professor of
radiology at New York Medical
College for almost ten years. He
was a member of the Radiology So-
ciety of North America, of our
Passaic County component, and of
the American Medical Associa-
tion; he was a fellow of the Ameri-
can College of Radiology.
Abram Vermeulen. General
surgeon, Abram Vermeulen, MD,
died May 6, 1990, at the age of 77.
He was a resident of Prospect Park
and Ridgewood. Born in Paterson,
on July 10, 1912, Dr. Vermeulen
received his medical degree from
Northwestern LIniversity Medical
School, Chicago, in 1936. He
served an internship at Paterson
General Hospital. Dr. Vermeulen
was affiliated with Wayne General
Hospital; Valley Hospital, Ridge-
wood; and Christian Health Care
Center, Wyckoff. In addition, Dr.
Vermeulen was a member of our
Passaic County component and of
the American Medical Associa-
tion; he was a fellow of the Ameri-
can College of Surgeons.
Julius Winston. Retired for
many years from the practice of
otolaryngology, Julius Winston,
MD, died on March 25, 1990, at
the age of 88. Born in Philadelphia,
Dr. Winston earned his medical
degree from Jefferson Medical Col-
lege, Philadelphia, in 1926. He
served his internship at St. Mary’s
Hospital, Philadelphia. Dr. Win-
ston received his Pennsylvania
medical license in 1927. He had his
practice for many years in Phila-
delphia before relocating to Atlan-
tic City; he received his license to
practice medicine in New Jersey in
1948. Dr. Winston was affiliated
with Temple University Hospital,
Philadelphia. Throughout his long
medical career, Dr. Winston was
professor of otolaryngology at
Graduate Hospital, University of
Pennsylvania, Philadelphia. Dr.
Winston also was a member of the
Philadelphia College of Physi-
cians, of the Philadelphia Laryn-
gological Society, of the American
College of Surgeons, of the Penn-
sylvania State Medical Society, of
our Atlantic County component,
and of the American Medical As-
sociation. From 1926 to 1931, Dr.
Winston served in the Medical Re-
serves as first lieutenant.
H. Edward Yaskin. Born in
Philadelphia, on November 7,
1909, H. Edward Yaskin, MD, died
at the age of 80. Dr. Yaskin earned
his medical degree from Jefferson
Medical College, Philadelphia, in
1935 and his New Jersey and Penn-
sylvania medical licenses the same
year. Dr. Yaskin served his in-
ternship at Cooper Hospital,
Camden, and residencies at three
New York facilities: Montefiore
Hospital, New York Psychiatric
Institute, and Mount Sinai Hospi-
tal. A neuropsychiatrist, Dr.
Yaskin had a practice in Penn-
sylvania before locating to New
Jersey. Dr. Yaskin served two neu-
rology fellowships in the early
1940s: the Abrahamson Fellowship
and the Ross V. Patterson Fellow-
ship. Dr. Yaskin was affiliated
with several hospitals: Camden
County Psychiatric Hospital;
Thomas Jefferson University Hos-
pital, Philadelphia; St. Luke’s and
Children’s Medical Center, Phila-
delphia. In addition, he was a
professor of the neurology depart-
ment at Thomas Jefferson Univer-
sity Hospital. Dr. Yaskin was a
member of our Camden County
component, of the Philadelphia
Neurological Society, of the Phila-
delphia Psychiatric Society, of the
New Jersey Neuropsychiatric So-
ciety, of the American Academy of
Neurology, of the American Psy-
chiatric Association, of the Ameri-
can Neurological Association, and
of the Philadelphia County Medi-
cal Society.
Send information to:
Membership Department
Medical Society of New Jersey
Two Princess Road
Lawrenceville, NJ 08698
594
NEW JERSEY MEDICINE
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
vision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statement accompany-
ing material offered to NEW JER-
SEY MEDICINE must contain the
following language and must be
signed by all authors.
“In consideration of NEW JER-
SEY MEDICINE taking action in
reviewing and editing my sub-
mission, the author(s) undersigned
hereby transfers, assigns, or other-
wise conveys all copyright own-
ership to the Medical Society of
New Jersey, in the event that such
work is published in NEW JER-
SEY MEDICINE.
Specifications. Submit two
manuscripts that must be type-
written and double-spaced on 8 Vi "
by IT' paper. Statistical methods
should be identified.
Authors are asked to seek clar-
ity, accuracy, and originality; at-
tention to details of grammar,
spelling, and typing are important.
The title page should include the
full name, degrees, and affiliations
of all authors, and the name and
address of the author to whom re-
print requests and correspondence
should be sent.
The author should submit a 30-
word abstract.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission must be
submitted.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote
with the first use of the generic
name. Proprietary names of de-
vices should be indicated by the
registration symbol — ®.
References should not exceed 35
citations except in review articles,
and should be cited consecutively
by numbers in parentheses at the
end of the sentence. The reference
list should be typewritten and
double-spaced on separate 8V2" by
11" sheets in numerical order. The
style of NEW JERSEY MEDI-
CINE for references is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
viewers and the authors will be
permitted, but authors will be in-
formed of the reviewers’ com-
ments. Galley proofs will be sub-
mitted to the author for correction.
Reprint Orders. Reprints may be
ordered after the author is notified
that the article has been selected
for a specific issue. A check for the
cost of reprints must accompany
that order.
Communications. All com-
munications should be sent to the
editor, NEW JERSEY MEDI-
CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
VOL. 87— NUMBER 7 JULY 1990
595
PRACTICE FOR SALE:
General Practice . . . active, established, growing
practice in beautiful Atlantic County beach community,
New Jersey.
Physician relocating out west.
Office fully equipped and furnished.
Available immediately. Physician will help with tran-
sition period.
For additional information please contact:
Mary Ann Hamburger
Mary Ann Hamburger, Associates
74 Hudson Avenue
Maplewood, New Jersey 07040
ELIZABETH— FOR SALE
• Professional office, ideal for medical group.
• Approximately 3,000 sq. ft.
• Reception area, offices, office with fireplace,
restrooms, kitchen.
• Loads of parking. Close to all major NJ high-
ways and NYC transportation.
Call Ray (201) 354-7530
FAMILY PRACTITIONER
Beautiful Bucks County office. Established 25
years. Seek Family Practitioner/Internist.
Call: Gale Wayman or Judy Bliss
215-295-8166
OFFICE SPACE
Available in Professional Building in Monroe
Township NJ, off exit 8A; surrounded by four re-
tirement communities. Half of building occupied
by active Dental Practice which could function as
good referral source. Option to buy into building.
Contact: David Rabinowitz, D.D.S.
609-655-3555
GET MORE FOR
YOUR RESIDENCY.
Become an Air Force sponsored resident
and remain in your training program
while you enjoy the pay and benefits of
an Air Force officer. Then serve two
years as an Air Force physician or spe-
cialist...enjoying a great start without the
financial/administrative burden of start-
ing a practice. Find out how to qualify for
Air Force residency. Call
USAF HEALTH PROFESSIONS
1-800-423-USAF
596
NEW JERSEY MEDICINE
NO-FAULT:
MSNJ GETS INJUNCTION
On July 11, 1990, Judge Lawrence L. Lasser, presiding judge of
the Tax Court, granted a temporary restraining order to the
Medical Society of New Jersey, requiring that the state maintain
any and all funds paid by doctors in a segregated account.
Judge Lasser further stated that the Society had demonstrated a
reasonable likelihood of success at a later hearing scheduled
for September 18. The relief granted is consistent with that
issued regarding lawyers, and the two cases have been
consolidated. MSNJ was represented by the firm of Kern
Augustine Conroy & Isele.
MEDICARE MANDATORY BILLING
Effective September 1, 1990, Medicare law requires physicians to
forward a bill to the part B carrier for all services that are
"non-assigned. " MSNJ and the American Medical Association are
seeking to repeal this law.
HCFA has announced that New Jersey physicians will be permitted
to use superbills to meet this requirement. The superbill
should be attached to the 1500 claim form and sent according to
instructions previously provided by Pennsylvania Blue Shield.
MEDICAL WASTE REFUNDS
Medical waste refunds have been sent by the Department of
Environmental Protection (DEP) to physicians who filed the
reports required by law. Forty percent of the physicians
entitled to a refund failed to process a request for a return of
money; these physicians will be contacted by DEP. Please
provide the information requested and return the form to DEP;
if you do not, your refund entitlement will revert to the state.
OMBUDSMAN FOR THE ELDERLY
AT IT AGAIN
The state ombudsman just announced he adopted regulations
regarding nursing home patients that are consistent with the
announcement made in August 1988. The Committee on Biomedical
Ethics of the Medical Society of New Jersey expressed outrage at
the arrogant stubbornness of the ombudsman in adopting his
ill-advised and misguided regulations.
The MSNJ Board of Trustees has authorized the filing of a suit
challenging the regulations. MSNJ will be represented by the
firm of Kern Augustine Conroy & Isele.
SUPREME COURT RULES
IN FAVOR OF PHYSICAL THERAPY BOARD
In a unanimous decision, the Supreme Court reversed the
Appellate Division and upheld regulations of the Physical
Therapy Board. Those regulations permit: examinations of
patients without physician direction, general instruction
without physician direction, and modification of a
physician-ordered treatment provided the modification is
consistent with physician direction.
A therapist may not initiate treatment without prior physician
direction nor may a therapist examine a patient for the purpose
of diagnosing disease or an organic condition.
All physicians must be alert to instances where the physical
therapist does examine and diagnose, and should report such
events in detail to MSNJ.
With regard to modification of treatment, patient safety and
professional liability concerns require that no modification
occur without the prior approval of the physician. This is
achievable if the physician states on prescriptions and orders
for physical therapy:
Treatment to be rendered only as indicated and
without modification. Any modification of treatment
is not consistent with this order unless prior
written authorization is issued.
PHYSICIAN ASSISTANT
PROPOSAL MOVES FORWARD
The State Board of Medical Examiners has succumbed to pressure
from UMDNJ and proposed a regulation to authorize physician
assistants in New Jersey.
The MSNJ House of Delegates has directed that MSNJ oppose this
action. A hearing is scheduled by the State Board of Medical
Examiners on August 15, 1990. MSNJ has retained Judge Herbert
Stern to represent the Society. Judge Stern supports our belief
that SBME does not have lawful authority to adopt such a
regulation.
Physicians should send their written comments to SBME, 28 West
State Street, Trenton, NJ 08625.
In addition to the legal arguments against this proposal, MSNJ
believes there has been an absolute failure on the part of SBME
to demonstrate a need for this hybrid type of practitioner who
is not a physician, but will function as one.
v
MSNJ
NEWSLETTER
PRACTICE The Department of Practice Management of the AMA is conducting the
MANAGEMENT following workshops in New Jersey: Joining a Partnership or Group
WORKSHOPS (September 6); Starting Your Own Practice (September 7-8); Insurance
Processing and Coding (September 10); ICD-9 Coding for Doctor’s Of-
fices (September 11); Advanced CPT-4 Coding (September 12); Medical
Collections Management (September 12); and Business Side of Medicine
(September 13). These workshops will be held at the Cherry Hill Inn,
Cherry Hill. For more information, please call 1/312/645-4958.
HEALTH CARE Governor Jim Florio, stating that there is a “health care cost crisis” in
COMMISSION the state of New Jersey, has established a Governor’s Commission on
Health Care Costs. The Commission has been charged with examining
all components of health care costs with a particular focus toward re-
forming the current uncompensated care payment system. The chairman
of the Commission suggested that major reform is necessary in several
areas: affordability of health care insurance, improved coordination of
the planning and financing of health care services, and reforming the
hospital reimbursement system to further contain costs. Commission
members include representatives from business, education, industry,
organized labor, and the Statewide Health Coordinating Council.
STATE HEALTH The State Commissioner of Health, Dr. Frances Dunston, called for the
PLAN development of an updated and comprehensive state health plan. Dr.
Dunston noted that the last state health plan was completed in the early
1980s. In addition to planning for the provision of the appropriate mix
and level of medical services, the Commissioner indicated that the state
health plan could be used as a means of controlling costs while improving
access to essential care. In an effort to support the planning process, Dr.
Dunston wants to continue the regional health planning agencies that
review certificate of need applications.
MOMS The Health Care Administration Board has decided to delay the im-
PROGRAM DELAY plementation of the Maternity Outreach and Managed Services
(MOMS) program. The MOMS program was to provide $3.7 million for
prenatal care for low-income, uninsured pregnant women. The delay was
requested by the commissioner of health due to questions surrounding
the funding of the program. The proposed method of funding was to draw
funds from the Uncompensated Care Trust Fund. However, the com-
missioner did not want to place any additional burdens on the Trust
Fund. An alternative that may be explored is expansion of Medicaid
eligibility guidelines for pregnant women.
TRANSPLANT The U.S. Court of Appeals for the Eighth Circuit has ruled an Iowa
COSTS Medicaid recipient, suffering from severe diabetes, should receive Medi-
caid coverage for her pancreas transplant. While the state had decided
to only cover procedures that were not considered “experimental” by
Medicare, the court felt that such designation by Medicare was not an
“absolute standard” but an “administrative convenience.”
VOL. 87— NUMBER 8 AUGUST 1990
607
MSNJ NEWSLETTER
County and Specialty Societies, Academy of Medicine
of New Jersey, MSNJ Auxiliary, and AMA Delegation
Attendance at Meetings of the Board of Trustees
January 1990— June 1990
Atlantic County
April 8 Kelly M. Reid, MD, President-
Elect
Bergen County
January 21 ... Matis A. Fermaglich, MD
February 18 .. Matis A. Fermaglich, MD
March 18 Matis A. Fermaglich, MD
Patricia G. Klein, MD, President-
Elect
April 8 Matis A. Fermaglich, MD
May 5 Alfred A. Alessi, MD
Burlington County
January 21 ... S. Manzoor Abidi, MD, President-
Elect
February 18 .. S. Manzoor Abidi, MD, President-
Elect
Charles J. Moloney, MD
March 18 S. Manzoor Abidi, MD, President-
Elect
May 9 S. Manzoor Abidi, MD, President-
Elect
Camden County
March 18 Joseph T. Sokolowski, Jr, MD,
President
May 5 George T. Hare, MD
Cumberland County
April 8 Gerald S. Packman, MD, President
Essex County
April 8 Anita Falla, MD
May 5 Arthur R. Ellenberger, Executive
Secretary
May 9 George L. Benz, MD, Secretary
Arthur R. Ellenberger, Executive
Secretary
Gloucester County
January 21 ... Churchill L. Blakey, MD
February 18 .. Churchill L. Blakey, MD
George S. Nicoll, MD, President
March 18 Churchill L. Blakey, MD
George S. Nicoll, MD, President
April 8 Churchill L. Blakey, MD
George S. Nicoll, MD, President
May 5 Churchill L. Blakey, MD
May 9 Churchill L. Blakey, MD
Hudson County
February 18 .. Russ C. Camangian, MD, President
March 18 Russ C. Camangian, MD, President
April 8 Russ C. Camangian, MD, President
May 5 Charles L. Cunniff, MD
Mercer County
January 21 ... Linda L. McGhee, Executive Director
February 18 .. William H. Hardesty, MD, President
Linda L. McGhee, Executive Director
John G. Winant, Jr, MD, President-
Elect
March 18 William H. Hardesty, MD, President
Linda L. McGhee, Executive Director
John G. Winant, Jr, MD, President-
Elect
April 8 Louis G. Fares, MD
Linda L. McGhee, Executive Director
John G. Winant, Jr, MD, President-
Elect
May 5 Louis G. Fares, MD
John G. Winant, Jr, MD, President-
Elect
May 9 Louis G. Fares, MD
June 10 Louis G. Fares, MD
Linda L. McGhee, Executive Director
Gabriel F. Sciallis, MD, President-
Elect
John G. Winant, Jr, MD, President
Middlesex County
February 18 .. Mary Alice Bruno, Executive Director
Leticia V. DeCastro, MD
March 18 Victor H. Boogdanian, MD
Leticia V. DeCastro, MD
April 8 Mary Alice Bruno, Executive Director
Leticia V. DeCastro, MD
Bernard A. Rineberg, MD
May 5 Mary Alice Bruno, Executive Director
Monmouth County
January 21 ... William J. D’Elia, MD
Walter J. Kahn, MD, President-Elect
March 18 William J. D’Elia, MD
Morris County
March 18 William J. Dowling, Jr, MD, Secretary
Passaic County
January 21 ... Michael H. Bernstein, MD, President
February 18 .. Michael H. Bernstein, MD, President
April 8 Michael H. Bernstein, MD, President
June 10 Michael H. Bernstein, MD, Immediate
Past-President
Salem County
May 9 Frank L. Redo, MD, President
Union County
January 21 ... A. Ralph Kristeller, MD
Irene Rosenthal, Executive Director
February 18 .. A. Ralph Kristeller, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
Bessie M. Sullivan, MD, President-
Elect
608
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
March 18 A. Ralph Kristeller, MD
Richard R. Lorber, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
Om P. Sawhney, MD, President
April 8 A. Ralph Kristeller, MD
Irene Rosenthal, Executive Director
Om P. Sawhney, MD, President
May 5 Andrea Donelan, Administrative
Assistant
A. Ralph Kristeller, MD
Frank R. Romano, Sr, MD
Irene Rosenthal, Executive Director
May 9 Bessie M. Sullivan, MD, President-
Elect
June 10 Richard R. Lorber, MD
Irene Rosenthal, Executive Director
Harold S. Yood, MD
April 8 Sandra Samuels, MD, President-Elect
New Jersey Obstetrical and Gynecological Society
January 21 ... John D. Franzoni, MD
February 18 .. John D. Franzoni, MD
March 18 John D. Franzoni, MD
April 8 John D. Franzoni, MD
June 10 John D. Franzoni, MD
New Jersey Academy of Ophthalmology and
Otolaryngology
January 21 ... Saul M. Tischler, MD, President
February 18 .. Saul M. Tischler, MD, President
April 8 Saul M. Tischler, MD, President
New Jersey Orthopaedic Society
February 18 .. Morton Farber, MD, Vice-President
New Jersey Chapter, American Academy of Pediatrics
March 18 Stephen M. Golden, MD
Warren County
January 21 ... Robert C. Emery, MD, President
February 18 .. Robert C. Emery, MD, President
March 18 Robert C. Emery, MD, President
New Jersey State Society of Anesthesiologists
January 21 ... Stanley Bresticker, MD
June 10 Stanley Bresticker, MD
New Jersey Association of Electromyography
and Electrodiagnosis
February 18 .. Kutumba S. Pitta, MD,
Vice-President
Michael Sutula, DO, President
March 18 Michael Sutula, DO, President
April 8 Kutumba S. Pitta, MD,
Vice-President
Michael Sutula, DO, President
May 5 Kutumba S. Pitta, MD,
Vice-President
June 10 Michael Sutula, DO, President
New Jersey Chapter, American College of Emergency
Physicians
January 21 ... Rudolf E. Schwaeble, MD
March 18 Rudolf E. Schwaeble, MD
April 8 Rudolf E. Schwaeble, MD
May 5 Rudolf E. Schwaeble, MD
May 9 Rudolf E. Schwaeble, MD
June 10 J. Mark Meredith, MD,
President-Elect
Rudolf E. Schwaeble, MD
New Jersey Psychiatric Association
January 21 ... Thomas R. Houseknecht, MD
February 18 .. Thomas R. Houseknecht, MD
American College of Surgeons, New Jersey Chapter
January 21 ... Ames L. Filippone, Jr, MD
February 18 .. Ames L. Filippone, Jr, MD
March 18 Ames L. Filippone, Jr, MD
New Jersey Society of Thoracic Surgeons
February 18 .. Javier Fernandez, MD, Vice-President
May 5 Javier Fernandez, MD, Vice-President
Academy of Medicine of New Jersey
January 21 ... Sherman Garrison, MD
Charles J. Heitzmann, Executive
Director
February 18 .. Ronnie Davidson, EdD, Associate
Director
Charles J. Heitzmann, Executive
Director
March 18 Ronnie Davidson, EdD, Associate
Director
Charles J. Heitzmann, Executive
Director
April 8 Charles J. Heitzmann, Executive
Director
May 5 Charles J. Heitzmann, Executive
Director
June 10 Sherman Garrison, MD
Charles J. Heitzmann, Executive
Director
New Jersey Society of Internal Medicine
January 21 ... Barry R. Zitomer, MD, President
March 18 Frank J. Malta, MD
April 8 Barry R. Zitomer, MD, President
May 5 Frank J. Malta, MD
June 10 Frank J. Malta, MD
New Jersey Association of Medical Specialty Societies
January 21 ... Stanley Bresticker, MD
June 10 Stanley Bresticker, MD
New Jersey Medical Women’s Association
February 18 .. Sandra Samuels, MD, President-Elect
Medical Society of New Jersey Auxiliary
January 21 ... Dorothy Espinola, Corresponding
Secretary
February 18 .. Dorothy A. Camangian, President,
Hudson County Medical
Society Auxiliary
Dorothy Espinola, Corresponding
Secretary
Sevim Omay, President
March 18 Dorothy A. Camangian, President,
Hudson County Medical
Society Auxiliary
VOL. 87— NUMBER 8 AUGUST 1990
609
MSNJ NEWSLETTER
Jane Lorber, President-Elect
April 8 Dorothy A. Camangian, President,
Hudson County Medical
June 10 ....
Society Auxiliary
Sevim Omay, President
.... Jane Lorber, President
AMA Delegation
AMA Delegates
AMA Alternate Delegates
January 21 ...
Frederick W. Durham, MD
Ralph J. Fioretti, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
January 21 ..
Harry M. Carnes, MD
Michael M. Heeg, MD
Paul J. Hirsch, MD
Joseph N. Micale, MD
Irving P. Ratner, MD
Carl Restivo, Jr, MD
William E. Ryan, MD
February 18 ..
Palma E. Formica, MD
Robert J. Weierman, MD
Karl T. Franzoni, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
Frank Y. Watson, MD
February 18 .
. Harry M. Carnes, MD
Michael M. Heeg, MD
Paul J. Hirsch, MD
Joseph N. Micale, MD
March 18
Ralph J. Fioretti, MD
Palma E. Formica, MD
Irving P. Ratner, MD
Robert J. Weierman, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
Robert H. Stackpole, MD
Frank Y. Watson, MD
March 18
Michael M. Heeg, MD
Paul J. Hirsch, MD
Donald J. Holtzman, MD
Joseph N. Micale, MD
Irving P. Ratner, MD
Carl Restivo, Jr, MD
William E. Ryan, MD
April 8
Palma E. Formica, MD
Karl T. Franzoni, MD
Robert J. Weierman, MD
John S. Madara, MD
Henry J. Mineur, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
Robert H. Stackpole, MD
April 8
Harry M. Carnes, MD
Michael M. Heeg, MD
Paul J. Hirsch, MD
Joseph N. Micale, MD
Carl Restivo, Jr, MD
William E. Ryan, MD
May 5
Frederick W. Durham, MD
Ralph J. Fioretti, MD
Robert J. Weierman, MD
Palma E. Formica, MD
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
Robert H. Stackpole, MD
Frank Y. Watson, MD
May 5
Harry M. Carnes, MD
Paul J. Hirsch, MD
Donald J. Holtzman, MD
Irving P. Ratner, MD
Carl Restivo, Jr, MD
William E. Ryan, MD
Robert J. Weierman, MD
May 9
Harrv M. Carnes, MD
May 9
Frederick W. Durham, MD
Ralph J. Fioretti, MD
John S. Madara, MD
Henry J. Mineur, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
Frank Y. Watson, MD
June 10
Paul J. Hirsch, MD
A. Ralph Kristeller, MD
Joseph N. Micale, MD
Carl Restivo, Jr, MD
William E. Ryan, MD
Robert J. Weierman, MD
Paul J. Hirsch, MD
June 10
Karl T. Franzoni, MD
John S. Madara, MD
Henry J. Mineur, MD
Joseph A. Riggs, MD
Edward A. Schauer, MD
Robert H. Stackpole, MD
Donald J. Holtzman, MD
A. Ralph Kristeller, MD
Irving P, Ratner, MD
Carl Restivo, Jr, MD
William E. Ryan, MD
Robert J. Weierman, MD
610
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
HIGHER Cautioning that HHS is moving too fast to control physician costs, the
DOCTOR Physician Payment Review Commission (PPRC) has recommended a
LIMITS f"iscal target increase in physician spending at 11.2 percent rather
than the 9.9 percent recommended by HHS. HHS has recommended a
lower increase in the growth in volume intensity of physican services by
proposing a 10.5 percent update for nonsurgical services and an 8.7
percent increase for surgical services. The PPRC recommends 12.1 per-
cent for nonsurgical services and 9.3 percent for surgical services.
O/P REVENUES The Prospective Payment Assessment Commission (ProPAC) has found
INCREASE that outpatient revenue has increased from 12.4 percent of total operat-
ing revenue in 1979 to 21.1 percent in 1989. ProPAC found that smaller
hospitals depend more on outpatient revenue than larger facilities. Inpa-
tient revenue has decreased from 83.2 percent in 1979 to 74 percent of
total operating revenue in 1989. Medicare spending for outpatient ser-
vices has increased by approximately 300 percent from $2 billion in 1989
to $7.9 billion in 1979.
Health and Human Services Inspector General Richard Kusserow has
concluded that hospital closures in 1988 did not reduce access to health
care. Kusserow’s conclusions were based on the fact that hospital
closures tended to occur for small hospitals that generally were less than
100 beds and had average occupancy levels of 30 percent, while access
to other facilities offering inpatient care was nearby. Hospital closures
in 1988 amounted to 88 facilities in 29 states with 50 rural facilities and
38 urban facilities ceasing operations. Patients had to travel no more
than ten miles in the urban areas that experienced hospital closings and
patients had to travel no more than 20 miles for 75 percent of the rural
facilities that closed.
St. Paul Fire and Marine Insurance Co. has filed for decreases in its
malpractice insurance premiums in 21 of the 42 states in which it
provides such coverage. These premium decreases average 6 percent. St.
Paul also has filed for rate increases in three states. This follows the
insurance company’s 1989 decrease in malpractice premiums averaging
16 percent in 34 states. The number of malpractice claims per 100
physicians has declined from 17 in 1985 to 12 in 1989. The average cost
per claim has increased from $28,300 in 1985 to $36,900 in 1989.
CLIA A proposed rule to implement the Clinical Laboratory Improvement
pgQUI'ATIONS Amendments (CLIA) of 1988 was published in the Federal Register, this
publication expands government regulation of laboratories to all settings
that perform quantitative, qualitative, or screening tests procedures.
This publication is followed by a 90-day period of formal comment.
There are presently three basic regulatory tiers — waiver, level I, and level
II. Significant changes are expected before the regulations are finalized.
The regulations now are tied to the “complexity” of tests. The proficien-
cy testing, patient test management, quality control, and quality as-
surance requirements are basically the same in both level I and level
II. On the behalf of office laboratories that barely qualify for level II,
physicians and instrument manufacturers already are calling for a third
tier, between level I and II. These tests would be based on instrument
complexity and would ease up the stringent personnel and laboratory
director requirements in level II. Comments must be received before
August 20, 1990. HCFA encourages physicians to comment to the follow-
ing address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HSQ-176-P, P.O. Box 26676,
Baltimore, MD 21207.
PREMIUM
DECLINE
HOSPITAL
CLOSURES
VOL. 87— NUMBER 8 AUGUST 1990
611
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LEVOXINE® ( Levothyroxine Sodium Tablets, USP) For oral administration
The following is a brief summary. Before prescribing, please consult package insert
INDICATIONS AND USAGE:
LEVOXINE(L-thyroxine) tablets are indicated as replacement or supplemental therapy
for diminished or absent thyroid function, resulting from functional deficiency, primary
atrophy, from partial or complete absence of the gland or from the effects of surgery,
radiation or antithyroid agents. Therapy must be maintained continuously to control the
symptoms of hypothyroidism.
CONTRAINDICATIONS:
L-thyroxine therapy is contraindicated in thyrotoxicosis, acute myocardial infarction
and uncorrected adrenal insufficiency.
WARNINGS:
Drugs with thyroid hormone activity, alone or together with other therapeutic agents, have
been used for the treatment of obesity. In euthyroid patients, doses within the range of daily
hormonal requirements are ineffective for weight reduction. Larger doses may produce
serious or even life-threatening manifestations of toxicity, particularly when given in as-
sociation with sympathomimetic amines such as those used for anorectic effects
PRECAUTIONS:
Caution must be exercised in the administration of this drug to patients with cardiovas-
cu lar disease. Development of chest pains or other aggravation of the cardiovascu lar dis-
ease requires a reduction of dosage
Patients on thyroid preparations and parents of children on thyroid therapy should be
informed that replacement therapy is to be taken essentially for life. They should im-
mediately report during the course of therapy any signs or symptoms of thyroid hormone
toxicity, eg, chest pains, increased pulse rate, palpitations, excessive sweating, heat
intolerance, nervousness, or any other unusual event In case of concomitant diabetes
mellitus, the daily dosage of antidiabetic medication may need readjustment In case of
concomitant oral anticoagulant therapy, the prothrombin time should be measured fre-
quently to determine if the dosage of oral anticoagulants is to be readjusted.
Partial loss of hair may be experienced by children in the first few months of thyroid
therapy, but this is usually a transient phenomenon and later recovery is usually the
rule
Drug Interactions — In patients with diabetes mellitus, addition of thyroid hormone
therapy may cause an increase in the required dosage of insulin or oral hypoglycemic
agents
Patients stabilized on oral anticoagulants who are found to require thyroid replace-
ment therapy should be watched very closely when therapy is started.
Cholestyramine binds both T4 and T3 in the intestine, thus impairing absorption of
these thyroid hormones. Four to five hours should elapse between administration of
cholestyramine and thyroid hormones
Estrogens tend to increase serum thyroxine-binding globulin (TBg). Patients without a
functioning thyroid gland who are on thyroid replacement therapy may need to increase
their thyroid dose if estrogens or estrogen-containing oral contraceptives are givea
Drug/Laboratory Test Interactions — The following drugs or moieties are known to inter-
fere with laboratory tests performed on patients taking thyroid hormone: androgens cor-
ticosteroids estrogens oral contraceptives containing estrogens iodine-containing
preparations and the numerous preparations containing salicylates
Carcinogenesis, Mutagenesis, And Impairment of Fertility — A reported apparent as-
sociation between prolonged thyroid therapy and breast cancer has not been confirmed.
No confirmatory long-term studies in animals have been performed to evaluate car-
cinogenic potential, mutagenicity, or impairment of fertility in either males or females
Pregnancy-Category A — The clinical experience to date does not indicate any adverse
effect on fetuses when thyroid hormones are administered to pregnant women.
Nursing Mothers — Minimal amounts of thyroid hormones are excreted in human milk
Thyroid is not associated with serious adverse reactions and does not have a known
tumorigenic potential. However, caution should be exercised when thyroid is adminis-
tered to a nursing woman.
Pediatric Use — The incidence of congenital hypothyroidism is relatively high. Routine
determinations of serum (T4) and/or TSH is strongly advised in neonates in view of the
deleterious effects of thyroid deficiency on growth and development
ADVERSE REACTIONS:
Adverse reactions are due to overdosage and are those of induced hyperthyroidism.
OVERDOSAGE — Excessive dosage of thyroid medication may result in symptoms of
hyperthyroidism, which may not appear for one to three weeks after the dosage regimen
is begun The most common signs and symptoms of overdosage are weight loss, palpita-
tion, nervousness, diarrhea or abdominal cramps, sweating tachycardia, cardiac arrhy-
thmias, angina pectoris, tremors, headache insomnie intolerance to heat and fever. If
symptoms of overdosage appear, discontinue medication for several days and reinstitute
treatment at a lower dosage level
Complications as a result of the induced hypermetabolic state may include cardiac
failure and death due to arrhythmia or failure
Dosage should be reduced or therapy temporarily discontinued if signs and symptoms
of overdosage appear.
Treatment of acute massive thyroid hormone overdosage is aimed at reducing gas-
trointestinal absorption of the drugs and counteracting central and peripheral effects,
mainly those of increased sympathetic activity. Measures to control fever, hypoglycemia, or
fluid loss should be instituted if needed.
DOSAGE FORMS AVAILABLE:
LEVOXINE (L-thyroxine) tablets are supplied as oval, color coded, potency marked
tablets in 1 1 strengths: 1 2Vi meg (0.0125 mg) - maroon, 25 meg (0.025 mg) - orange,
50 meg (0.05 mg)- white, 75 meg (0.075 mg) - purple, 100 meg (0.1 mg) -yellow, 112 meg
(0.112 mg) - rose, 125 meg (0.125 mg) - brown, 150 meg (0.15 mg) - blue, 175 meg
(0.175 mg) -turquoise, 200 mcg(0.2 mg) -pink and 300 mcg(0.3 mg) -green, in bottles of
100 and 1000, and unit dose in cartons of 100 (10 strips of 10 tablets), 200 meg and
500 meg injectable (see injectable package insert).
612
NEW JERSEY MEDICINE
PROFESSIONAL
LIABILITY
CONFIDENTIALITY OF A recent decision in the Superior Court, Ocean County, holds a great
PEER REVIEW deal of significance for the hospital peer review process. In Bundy versus
Mirescu, MD, et ah, Docket No. L-6787-1-88 (Law Div. 1990), the Court
held that evaluations, opinions, and criticisms of peer review committees
are not subject to discovery in medical malpractice cases.
Information and data gathered by utilization review committees in hos-
pitals are absolutely privileged by statute, N.J.S.A. 2A:84A-22.8. How-
ever, information developed by other hospital committees are not
protected by statute (Young versus King, 135 N.J. Super. 127, Law Div.
1975). Six years ago our courts began to develop the common law privi-
lege of self-critical analysis, that holds there should not be disclosure
of confidential critical, evaluative, or deliberative material if the public
interest in confidentiality outweighs an individual’s need to obtain the
information, Wiley versus Mills, 195 N.J. Super. 332 (Law Div. 1984).
In the Bundy case, the court applied the privilege of self-critical analysis
to the peer review process. The court stated: “The peer review process,
born of a regulatory requirement, is not motivated by a purely altruistic
desire to improve health care. However, the purpose of the process is
self-evaluation and health care improvement. This court, therefore, must
characterize the peer review process as a self-critical process. The public
benefits from a peer review committee that is free to express its opinions,
evaluations, and criticisms. These statements provide the basis for
change and improvement. To reveal such material would inhibit candor
and stifle improvement. The opinions, criticisms, and evaluations con-
tained within the peer review file come within the self-evaluation privi-
lege and are absolutely protected.”
This decision of a law division judge in Ocean County is not, of course,
binding on other trial courts. Nonetheless, the Bundy opinion is signifi-
cant for hospitals and medical staffs who wish to maintain the confiden-
tiality of their peer review proceedings. Henceforth, there will be a case
to rely upon to resist the discovery of evaluative material developed by
peer review committees in hospitals when such information is sought by
parties, particularly malpractice plaintiffs, in court proceedings. While
certain factual information developed by such committees may be dis-
coverable under the Bundy opinion, particularly where the information
is not already in the possession of the plaintiff and he has no other means
to obtain it, the opinion adds significant protection to the peer review
process. (Joseph M. Gorrell, Brach, Eichler, Rosenberg, Silver, Bern-
stein, Hammer & Gladstone, Roseland)
A trial court’s judgment that evidence was insufficient to find a phy-
sician guilty of an attempted unlawful abortion constituted an acquittal
and thus precluded a retrial, the Indiana Supreme Court ruled.
The physician was indicted for performing an abortion in violation of
the requirement that it be performed in a hospital. He entered a plea
of not guilty, and a trial began on February 4, 1980. The trial court
granted the physician’s motion for judgment on the evidence that the
NO RETRIAL OF
PHYSICIAN FOR
ALLEGED UNLAWFUL
ABORTION
VOL. 87— NUMBER 8 AUGUST 1990
615
PROFESSIONAL LIABILITY
patient did not abort. The case went to the jury on the included offense
of attempted performance of an unlawful abortion. The jury was dead-
locked after seven hours, and the court declared a mistrial. The state
filed a motion to correct errors, and the court denied it.
On appeal, the Indiana Supreme Court reversed the decision. The trial
court erred in granting judgment for the physician because he had
committed substantial steps towards performing an abortion, the court
said. The patient, who was five-and-one-half to six months pregnant,
went to a clinic for an abortion. She paid for the procedure and signed
a consent for an abortion. The physician examined her, told her he could
not perform a suction curettage, and said something else would have to
be done. The patient returned a week later for the procedure. The
physician inserted dilators into her cervix and gave her four or five
injections in her stomach. She was given prescriptions for antibiotics and
two other drugs, one to dry up her milk and the other to contract her
uterus the next day if she had not gone into labor. The night after the
procedure the patient became ill and was admitted to a hospital. She
was incoherent and so ill that in the opinion of the obstetrician she would
die if nothing were done. The obstetrician performed a caesarean section
and delivered a live baby boy, who died two hours later.
The Indiana Supreme Court said that the state had presented some
evidence on each of the three elements it had to prove for a conviction:
that the physician knew the patient was beyond her first trimester; that
he performed a substantial step towards an abortion; and that the
procedure was not conducted in a hospital. The trial court should not
have granted the physician’s motion, the Indiana Supreme Court said
in reversing the trial court’s decision. The physician then appealed to
the U.S. Supreme Court and certiorari was denied.
In 1987, after many delays, a trial court dismissed the charge against
the physician on the basis of changes in the law governing double jeop-
ardy that had occurred since the Indiana Supreme Court’s 1981 reversal
of the first trial court’s decision. The state then appealed, asserting that
the Indiana Supreme Court’s 1981 ruling was the law of the case.
On appeal, the Indiana Supreme Court upheld the second trial court’s
discharge of the physician. Following the lead of the U.S. Supreme Court
in a 1986 case, the Indiana Supreme Court had held in a 1987 case that
the grant of a judgment by a trial judge is tantamount to an acquittal
that bars retrial. The judgment in the physician’s original trial for
attempted abortion, following a mistrial, was based on the court’s find-
ing that there was insufficient credible evidence for a conclusion of guilt.
A second trial on the same charge was precluded because to retry the
physician would violate the constitutional prohibition against double
jeopardy for the same offense, the court said. For purposes of the double
jeopardy clause, a judgment that the evidence is legally insufficient to
sustain a guilty verdict constitutes an acquittal even if the order was
not designated an acquittal and was erroneous.
The court also disagreed with the state’s contention that under the law-
of-the-case doctrine, an appellate court’s determination of a legal issue
is binding in subsequent appeals. According to the court, the doctrine
is a discretionary rule of practice and not a uniform rule of law. To retry
the physician on a charge of which he was acquitted eight years before
from adherence to a discretionary rule of practice would be manifest
injustice, the court concluded. (Reprinted with permission from The
Citation, American Medical Association, Vol. 60, March 15, 1990)
616
NEW JERSEY MEDICINE
EDITOR’S
DESK
1990 UPDATES Another year. Another convention. Another taking arms against a sea
of troubles. All to the beat of the slot machines at Sands by the sea.
Many of the problems noted during the 1989 Annual Meeting continue,
although the battlelines were somewhat attenuated and the fighting
similarly diminished. Nevertheless, your attention is directed to a careful
reading of the 1990 Transactions, beginning on page 674, including the
following:
1. Changes in emeritus status and in the dues structure.
2. Requests that approaches to HIV be updated, that HIV infections
be treated as other communicable diseases, and that hospital testing be
done on all patients when medically indicated.
3. Requests that reviewing organizations utilize physicians licensed
in New Jersey and that physicians be allowed to perform office labora-
tory tests on a more reasonable basis.
4. Requests that Medicare policy be changed — that our physicians
not have the onus of billing for patients nor the onus of the present
carrier, who abolished its tollfree line.
5. Maintenance of our longstanding policy against the need for
physician assistants in New Jersey.
6. Request for MSNJ representation on the Governor’s Commission
on Health Care Costs, due to report in October — and which request, as
usual, has been ignored.
Plus officer and committee reports, tort reform, etc. One additional
note — too many delegations showed vacancies in their roster of delegates
and alternates. Is it again time to consider reapportioning the House of
Delegates?
And next year — Agra on the Atlantic.
AMA HONORS Kudos to our own, whose talents and previous honors are so well known
to us, who among many other distinctions, both chaired the Board of
Trustees of the Medical Society of New Jersey and received the Edward
J. Ill Distinguished Physician Award from the Academy of Medicine of
New Jersey:
• Palma E. Formica, MD, newly elected trustee of the American
Medical Association, whose election was long overdue.
• James S. Todd, MD, the new executive vice-president of the
American Medical Association, whose selection enhances the pres-
tige of both the AMA and its Board.
It has been my privilege to work with these two outstanding physicians
over many years and, more significantly, to be their friend. Long may
it continue. □
GUEST As part of our new initiatives to prepare future physicians to address
EDITORIAL the revolutionary changes taking place in the United States health care
delivery system, University of Medicine and Dentistry of New Jersey-
VOL. 87— NUMBER 8 AUGUST 1990
619
EDITOR’S DESK
Robert Wood Johnson Medical School has established clinical preven-
tion as the overall theme that guides our medical educational efforts.
The initiative supports a medical school curriculum that continues to
develop with its current organization and content, but with one major
addition — a new mindset of faculty and students directed toward clinical
prevention in all aspects of the physician-patient encounter. In addition,
the clinical prevention initiative is designed to have a positive impact
on the preventive aspects of the care provided by physicians currently
practicing in New Jersey.
Extension of the clinical prevention concept to impact on practice pat-
terns of New Jersey is occurring first as a result of departmental inter-
actions with physicians and other preceptors at sites where students are
placed for clerkships and residencies. Another opportunity to share
preventive strategies is at conferences, such as the “Interdisciplinary
Symposium on Prevention and Control of Lyme Disease,” that drew
nearly 500 participants to the medical school primarily from the tri-state
area. Highlights of the major papers at this symposium were included
in the July issue of NEW JERSEY MEDICINE.
A new section of the journal will be dedicated to articles authored by
UMDNJ-Robert Wood Johnson Medical School faculty members regard-
ing clinical prevention strategies. The special section will be entitled,
“Clinical Prevention Grand Rounds,” and will address the preventive
aspects of such topics as diet, exercise, and hypercholesterolemia, travel-
ler’s diarrhea, and human papilloma viruses and cervical neoplasia. This
is an exciting new venture between UMDNJ-Robert Wood Johnson
Medical School and NEW JERSEY MEDICINE and affirms our joint
commitment to provide practicing physicians with the latest techniques
to prevent as well as to treat disease. □ Norman H. Edelman, MD,
Dean, UMDNJ-Robert Wood Johnson Medical School
620
NEW JERSEY MEDICINE
BOOK
REVIEWS
ALLERGIC DISEASES C. Warren Bierman and David S. Pearlman. Philadelphia, PA, W.B.
FROM INFANCY TO Saunders, 1988. This textbook is dedicated to specific areas of im-
ADULTHOOD mun°l°gical diseases that are among the most rapidly developing areas
in the study of medicine. The increasing rate of mortality associated with
asthma reflects the importance of understanding atopic disorders, i.e.
that asthma is mediated by inflammatory mediators released with the
activation of mast cells. It has become apparent that immunology, in
general, is becoming a component of almost all fields of medicine, cutting
across many disciplines and various age groups ranging from the pedi-
atric to the adult and geriatric populations. Specifically, allergy in the
field of clinical medicine involves the general integration of several
disciplines and requires intricate weaving of immunology, pathology,
physiology, pharmacology, and pulmonology. This text focuses on the
immunological process known as allergy, which involves the IgE anti-
body; the authors utilize the term “atopy” in terms of the constellation
of complexes of symptoms and signs that exhibit similar features, e.g.
a familial (possibly hereditary) basis of a hypersensitivity to mediators
of inflammation and a process that precipitates or aggravates the trigger-
ing of this mechanism(s), but not necessarily with IgE antibody. These
triggers may include other processes that can directly activate the mast
cell (the ‘allergy’ type cell), e.g. by complement activation, drugs
(opiates), and neuropeptides.
Therefore, the book in its presentation and orientation, provides an
appropriate clinical background for the generalist interested in the
evaluation of a disease process that commonly involves over 40 million
individuals in the United States. □ Leonard Bielory, MD
GERIATRIC MEDICINE Kim Goldenberg, MD, and Alice Faryna, MD. Williams & Wilkins,
FOR THE HOUSE Baltimore, MD, 1990. This soft-covered book is one of a house officer
Qpp|£gp series published in 1990. It was written “to provide residents with a
fundamental knowledge of clinical geriatrics and to introduce them to
the essentials of an interdisciplinary approach.” It does this clearly.
The textbook essentially is a synopsis of geriatrics, useful to the private
physician as well as the house officer, to start thinking about this
subspecialty-with-a-difference within internal medicine. This per-
spective is in five major areas: general; organ system diseases; neu-
romuscular and related problems; psychosocial; and interdisciplinary
(legal, ethics, and placement). Competence, Alzheimer’s disease, and do
not resuscitate orders all are mentioned and are all major issues.
Regardless of general experience, the reader is sure to benefit from the
textbook and many tables in this subspecialty primer. It is less detailed
than Merck’s Manual of Geriatrics, which could follow easily. Examine
both to match your needs. □ Morris Soled, MD
NEUROSCIENCE: Brian A. Curtis, PhD. Lea & Febiger, Philadelphia, PA, 1990. The
Ylfg BASICS authors have written this text for students in nursing, occupational
therapy, and physical therapy. Contents include sections dealing with
VOL. 87— NUMBER 8 AUGUST 1990
623
BOOK REVIEWS
the basic anatomy and physiology of nerve and muscle, spinal cord, brain
stem and cerebellum, and cerebrum. Also, there are chapters on move-
ment, language, and neurochemistry and neuroimaging.
There is a fair amount of basic neurophysiology and neurochemistry
described in reasonable detail. Illustrations are quite good and well
reproduced for a paperback volume. From time to time, brief references
are made to disease entities and case histories appear in the midst of
basic text material for illustrative purposes. These also are given at the
end of chapters, where self-test questions usually are provided. Un-
fortunately, answers are not given for the test questions and case studies.
Nevertheless, the questions do provide students with a basis to test their
comprehension of each chapter.
This compact book packs a great deal of information into a small pack-
age for students. It is presented in a simple, straightforward, and easy-
to-read fashion, and nevertheless is fairly complete. References also are
provided. The book can be recommended for students in the allied health
fields and also should be of interest to most medical students. □ Stanley
C. Leonberg, Jr, MD
OCULAR S. Lerman and R.C. Tripathi. New York, New York, Marcel Dekker,
TOXICOLOGY ^ nc ■’ 1990. This textbook represents the proceedings of the first ocular
toxicology meeting held in Toronto, Canada, in 1988.
The text is organized by chapters devoted to each of the compartments
of the eye, i.e. anterior chamber, cornea, retina. The chapters are the
actual manuscripts submitted for presentation, and reflect basic re-
search in these areas. Practical clinical use is limited since many of the
manuscripts describe techniques to evaluate the toxic effects of a variety
of agents, e.g. cytotoxic agents, preservatives, or antibiotics. The text
could be a useful adjunct to anyone interested in basic ocular research
in corneal transplants or the topical application of drugs to the eye.
□ Leonard Bielory, MD
PRACTICE MADE Edna Kaplan. Boston, MA, Barrington Press, 1990. This is a 261-page,
PERFECT hardcover book of physician-patient relations, interpersonal communica-
tion, medical practice, and marketing medical care. It was written by
a public relations practitioner with over 20 years of experience in the
medical field.
This book is useful to the new practitioner who has no prior experience
in business; the text gives a first panorama of today’s changing outlook
on medicine as a business to be promoted. The seasoned doctor will have
absorbed much of this information by personal experience, but there are
prepared forms and sample brochures useful to those in mid-career.
The five-part book includes: the new reality, including “A Drop in
Esteem,” “Adapting to a More Hostile Environment,” and “Need for
Action,” which is to hire marketing consultants, find market niches, and
reshaping unrewarding careers; conservation communications strategies
(self, staff, and practice assessment, and a six-page patient questionnaire
that touches on the physician’s manner, fees, bills, delinquent accounts,
answering service and coverage, and evaluation by the patient); an
aggressive communication strategy including marketing public relations,
advertising and do-it-yourself ideas, media attention, hiring a consul-
tant, and reshaping an unrewarding career; aggressive communication
including paid promotions and advertising; and a summary guide.
Show this book to your library committee; it is useful as a medical
economics book, but not the only one. □ Morris Soled, MD
624
NEW JERSEY MEDICINE
Z LETTERS &
VIEWPOINTS
PHYSICIANS Should a physician take care of his relatives or friends? Draw your own
AND PATIENTS conclusions from these three real-life situations.
A surgeon colleague is sought after by an elderly relative who needs major
surgery. What happens if the physician fails to cure? He is brought to
a new word in physician-patient relations — enmeshment. This word is
not the same as gratitude. It is the state of being involved without clearly
defined rules. In this two-way coin toss, there is risk of “heads-I-win,
tails-you-lose.” Let’s hope he comes out peacefully.
A friend and business associate of many years went to a physician in
Manhattan when he was well and then called me to make a house call
when he was sick in Jersey City. I asked him to get the laboratory reports
from the doctor in New York but he never did. So, should I take a large
risk in treating the patient without knowing his last laboratory work or
x-ray reports? A few weeks later his alarmed wife called; his symptoms
at night suggested a surgical condition, and I advised her to call the
doctor in New York. It ended with a serious operation in New York.
Suppose I had taken care of him and a bad result followed, what would
he have said? Avoid a situation without continuity of care. Continuity
of care is one of the cornerstones of modern geriatric practice, and its
importance, including medicolegal implications, cannot be overstated.
The patient who goes to a New York doctor and only wants a house call
doctor here, as if he were a second class of practitioner, is so unrealistic
that, in my experience, such a relationship will end up without apprecia-
tion for your efforts or the respect needed to function against odds. Avoid
“two-tier medicine” — with you on the lower tier! The Park Avenue
patient will not give you much satisfaction, in my 32 years of house call
experience, and you can best hope only to come out even.
A third category is that of a longtime friend who seeks to become
attached as a patient, although not treated for over 10 years. Now, being
about 50 years of age, he is looking for a steady doctor, and does not
want to let go of his old friend. There is no amount of reasoning to show
him that medical practice must be objective, and good doctors do not
always win. It is necessary to have patients who can become displeased
and leave to go to someone else if they wish. The very dependent friend
does not want to see anything but his immediate need for a checkup,
even though you can see much further. Better to lose a friend now than
risk an enemy later. Of course, he was a “sore loser,” but the truth does
not change for dependent people who know you a long time — medical
care is best given by strangers. A good referral by you as a friend is worth
a great deal, if you can make such a friend appreciate it.
There is a Greek papyrus of the second century bearing these words —
“Jesus saith, a prophet is not received in his own country, nor doth a
physician heal his neighbors.” □ Morris Soled, MD
SBME DISCIPLINE Scanning the disciplinary columns of the State Board of Medical Exam-
iners newsletter in previous years, I could feel sorry for those listed. But
/OL. 87— NUMBER 8 AUGUST 1990
627
it was not until I saw my namesake (Morton S. Goldstein, License
#23157) on the list that I really became aware of what it felt like to join
this pitiful group. Now I feel the pain of acrimonious public humiliation.
It is unfair and unjust to punish impaired physicians with notoriety
much in the same way that it would be cruel to humiliate any other
group of sick, infirmed, crippled, or debilitated individuals. Publicizing
the names of our alcoholics and drug abusers could be seen as an attempt
to intimidate those of us who are functionally healthy while certainly
driving those of us with problems into the closet. How can the Medical
Society of New Jersey Physicians’ Health Program hope to find and treat
sick doctors in such an environment?
Rather than just seeking a clarification to point out that Morton S.
Goldstein, MD, is not Morton H. Goldstein, MD, I should like to see
this incident spark a positive turn in SBME public policy; for it seems
to me that the medical examiners could protect the public by leasing
and lifting of licenses, without the harsh publicity! I hope my colleagues
will be stirred to similar response. □ Morton H. Goldstein, MD
CHARITY WORK BY
HOSPITAL PHYSICIANS
In enumerating some charities performed by doctors, Doctor Costabile,
in his inaugural address (87:471-472, 1990), omitted the most important
of all: charities performed by doctors connected with hospitals. Doctors
run their medical staffs; that imposes upon them the obligation of mem-
bership on all committees mandated by inspecting authorities. Thus, the
average staff member may find himself spending about 60 hours a year
at meetings to help run the hospital. The average locum tenens pays
about $30 to $40 an hour. Thus, at $35 per hour, doctors contribute about
$2,100 each in free time. Multiply this by even so paltry a figure as 5,000
doctors, and in New Jersey alone, the medical contribution to hospital
affairs, at the very least, is about $10 million. For some reason, hospitals
do not factor this into their costs when measuring reimbursement. Why
not? They charge for everything else. And if they do not, they should
at the very least exhibit a large placard at the hospital door or perhaps
near the brass donor lists, enumerating the real-time contribution of
doctors to the hospital. Hospitals should advertise in newspapers this
contribution by doctors. And if hospitals refuse, then the Medical So-
ciety should beef up its anemic advertising with this piece of infor-
mation. □ Charles Harris, MD
LETTERS TO
THE EDITOR
Letters to the editor-in-chief of NEW JERSEY MEDICINE are wel-
come. Communications should be sent to NEW JERSEY MEDICINE,
the Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648.
628
NEW JERSEY MEDICINE
Tracheal Stenosis
JEAN-PHILIPPE BOCAGE, MD
ROBERT CACCAVALE, MD
RALPH LEWIS, MD
GLENN SISLER, MD
JAMES MACKENZIE, MD
A case report of tracheal stenosis is used to review the pathophysiology and
surgical management of symptomatic tracheal stenosis following intubation
and/or tracheostomy. The authors discuss tracheal resection and
reconstruction, the preferred permanent method of managing benign
tracheal stenosis.
Cicatricial response to erosive changes in the
tracheal wall from intubation and trache-
ostomy can produce a variety of lesions, re-
sulting in the need for tracheal resection and re-
construction. In 1971, Andrews and Pearson reported
an 18 percent incidence of functional stenosis in
patients managed by tracheostomy and assisted
ventilation.1 Although low-pressure and high-com-
pliance cuffs, introduced by Grillo and Cooper have
dramatically decreased the incidence of cuff
stenosis, such devices can produce tracheal injury if
overinflated.2 Other causes of stenosis include
sclerosing mediastinitis, postinflammatory changes
following diphtheria, and, rarely, tuberculosis,
amyloidosis, and congenital stenosis.3-4
We illustrate our tracheal stenosis experience with
a case history from Robert Wood Johnson University
Hospital.
Drs. Bocage, Caccavale, Lewis, Sisler, and MacKenzie
are affiliated with the Department of Surgery, UMDNJ-
New Jersey Medical School, New Brunswick. Requests
for reprints may be addressed to Dr. Caccavale, 185
Livingston Avenue, New Brunswick, NJ 08901.
CASE HISTORY
A 51-year-old male was admitted to an affiliated
medical center following a motor vehicle accident.
He had a depressed frontal skull fracture with acute
subdural hematoma and distal lower extremity
closed fractures. Following emergency craniotomy,
the patient developed prolonged ventilator de-
pendency, with tracheostomy performed after three
weeks of endotracheal intubation with a #8 Shiley®
(low pressure, cuffed) tracheostomy tube.
The patient eventually was weaned from the ven-
tilator, and the tracheostomy tube was removed four
weeks after insertion. Two weeks after tracheostomy
removal, the patient developed dyspnea and ex-
piratory wheezing. Fiberoptic laryngoscopy revealed
tracheal narrowing 2 cm below the vocal cords with
normal glottis and subglottic larynx. The patient
was transferred to our institution for evaluation and
treatment.
At the time of transfer, the patient was awake,
alert, and communicative. He had mild dyspnea and
a loud expiratory stridor. Arterial blood gases re-
vealed pH of 7.41, pA02 of 81, and pC02 of 40.
VOL. 87— NUMBER 8 AUGUST 1990
631
Figure 1. Narrowing of the trachea below the larynx, about 3
cm long and approximately 8 mm wide.
Cervical soft tissue films and computed axial tomog-
raphy scan demonstrated tracheal narrowing begin-
ning 2 cm below the vocal cords and extending for
2 cm (Figure 1). The patient was treated with hu-
midified inspired air and scheduled for tracheal re-
section. Four hours prior to surgery, the patient de-
veloped acute respiratory distress and worsening
stridor. Then, the patient was taken to the hospital
operating room and anesthetized by mask with
halothane and 02.
A #3 (6.6 mm) Hollinger® ventilating broncho-
scope was passed through the severely stenotic area.
The stricture then was dilated with successively
larger rigid scopes until a # 7 (10.7 mm) Hollinger®
scope could be passed. Careful bronchoscopic exam-
ination of the distal trachea revealed normal find-
ings. Endotracheal intubation then was achieved
with a #6 Hollinger® tube.
The trachea was exposed through the old
tracheostomy scar and the lesion identified. The op-
erative findings correlated with radiologic findings.
The stricture had formed in the area of the previous
tracheostomy stoma. The lesion was dissected cir-
cumferentially with division of the trachea below the
stenotic area.
The distal trachea was intubated with a new ster-
ile endotracheal tube and connected to the
anesthesia machine with sterile corrugated tubing
across the operative field. The first endotracheal
tube was pulled back into the larynx, and 2.5 cm
of stenotic tissue was excised. With the neck in ex-
treme flexion, the trachea was approximated
without tension, and anastomotic sutures (Vicryl®)
were placed. The second anesthesia tube was re-
moved and the orotracheal tube was advanced
across the anastomosis. The sutures were tied with
the knots on the outside and the suture line then was
covered with a pedicle of strap muscles. The patient
was extubated in the operating room. Flexion of the
neck was maintained by suturing the chin to the
chest. His postoperative course was unremarkable.
Examination of pathologic specimens revealed
subepithelial fibrosis. Seventeen days after surgery,
the patient was transferred to a rehabilitation center
for post-traumatic care.
The patient developed recurrent stridor several
months after discharge. Evaluation by an otolaryn-
gologist revealed granulation tissue 5 cm below the
vocal chords. The area of the anastomosis below the
cricoid was widely patent. The patient was managed
with several endoscopic laser treatments. At the
present, the patient is asymptomatic and doing well.
DISCUSSION
Post-tracheostomy lesions occur mainly at two
places: the stoma (tracheal opening) and the site of
the balloon cuff (Figure 2.) At the stomal level, an-
terolateral stenosis is seen. At the cuff level, circum-
ferential stenosis occurs at a position lower than seen
with a tracheostomy tube. The segment between
often is inflamed and malacic. As illustrated by our
patient, a combination of these two lesions occurs
in a small percentage of patients.4 In 1970, Lindholm
showed that, as early as 48 hours after intubation,
endotracheal tubes may cause a variety of ab-
normalities such as glottic edema, vocal cord granu-
lation, erosion over the arytenoids, and laryngeal or
subglottic stenosis.5
Pathogenesis of tracheal stenosis has been studied
extensively.1' 6 The fundamental lesion begins with
inflammation, followed by mucosal ulceration lead-
ing to necrosis and absorption of underlying
cartilage. Reparative healing leads to scar forma-
tion. Lesions at the tracheostomy site involve the
anterior and lateral walls, forming a triangular area
of narrowing.7 Inflammatory changes can be seen
within 24 to 48 hours. Andrews and Pearson noted
that circumferential ulceration secondary to pres-
sure necrosis at the cuff level is a precursor of
stenosis. Other etiologies include hypotension during
mechanical ventilation, tracheal infection, and the
irritative quality of tubing material.1
SIGNS AND SYMPTOMS
The trachea, approximately 10 to 12 cm long and
1.5 to 2.2 cm wide, begins at the inferior border of
the cricoid cartilage and extends to the level of the
carina. Adjacent structures are the thyroid gland,
which adheres to the second and third tracheal rings,
and the recurrent laryngeal nerves in the tracheo-
esophageal groove. Awareness of the complications
following tracheostomy can help diagnose tracheal
stenosis. This especially is true of mild to moderate
stenosis, that may be misdiagnosed as asthma. Dys-
pnea on exertion has been reported to be an in-
variable component that may be overlooked in a
632
NEW JERSEY MEDICINE
patient with known obstructive pulmonary disease.
Although usually absent, stridor can be apparent
when the tracheal lumen is less than 5 mm. The
patient also may complain of increased difficulty in
bringing up sputum. Brassy cough is a common find-
ing in patients with a functional stenosis.8 According
to Grillo, symptoms of upper respiratory obstruction
usually appear within two months after extubation,
but can be delayed up to two years. Grillo rec-
ommends assessment for tracheal stenosis in any
patient with symptoms of airway obstruction who
has been intubated for longer than 48 hours within
the previous two years.4 Previously published data
report a 17 to 20 percent incidence of post-
tracheostomy stenosis but more recent data is not
available to our knowledge.1'7 Not all patients de-
velop stenosis following intubation. Only sympto-
matic patients should be evaluated for possible
tracheal stenosis. When the lumen of the trachea is
reduced by 30 to 40 percent, most patients become
symptomatic and respiratory distress develops when
greater then 80 percent of the airway is com-
promised.
DIAGNOSTIC STUDIES
Normal lung fields usually appear on the chest
radiograph. Lateral neck films are useful in detect-
ing most lesions of the upper trachea. Fluoroscopy
helps to demonstrate malacia and vocal cord func-
tion. Tomograms give precise measurement of the
distance of the lesion from landmarks such as the
cords and the carina. Finally, CAT scan, though of
limited value in the evaluation of benign stenosis,
helps determine extent of neoplastic invasion. The
larynx must be evaluated properly preoperatively, as
there may be associated stenotic lesions at the glot-
tic and subglottic levels. If the laryngeal airway is
considerably impaired, the patient will not benefit
from tracheal repair alone, and repair of the
laryngeal lesions becomes mandatory prior to
tracheal reconstruction.7 Bronchoscopy is required
but should be reserved until a definitive treatment
plan has been made. Bronchoscopy allows a visual
assessment of the stricture, including its pliability
and the presence of inflammation and/or ulceration.
Rigid bronchoscopy with pediatric scopes, under
general anesthesia, can be used to dilate severe
stenosis for emergency relief and control of airway
before operative repair.3
MANAGEMENT
The preferred permanent method of managing
benign stenosis is tracheal resection and reconstruc-
tion. Temporary methods include serial dilatation,
stenting using Montgomery® T-tubes, reinsertion of
tracheostomies, systemic administration of steroids,
and repeated tissue destruction with forceps or
Figure 2. Diagram of principal postintubation lesions. A, Lesion
at cuff site in a patient who has been treated with an en-
dotracheal tube alone. The lesion is high in the trachea and is
circumferential. B, Lesions that occur with tracheostomy tubes.
At the stomal level, anterolateral stenosis is seen. At the cuff
level, lower than with an endotracheal tube, circumferential cuff
stenosis occurs. The segment between often is inflamed and
malacic. C, Damage to the subglottic larynx. A high
tracheostomy or one that erodes back by virtue of the patient's
anatomy may damage the inferior cricoid and produce a low
subglottic stenosis as well as an upper tracheal injury. D,
Tracheoesophageal fistula (TEF). The level of fistulization
usually is where the cuff has eroded posteriorly. Occasionally,
angulation of the tip of the tube may produce erosion from the
tip. There also is usually severe circumferential damage at this
level by the cuff. E, Tracheoinnominate fistula (TIF). A high-
pressure cuff frequently rests on the trachea directly behind the
innominate artery. Erosion may occur, although rarely. The
more common innominate artery injury is from a low
tracheostomy where the inner portion of the curve of the tube
rests in proximity to the artery and causes direct erosion. (Re-
printed by permission. Grillo HC, J Thorac Cardiovasc Surg
78:860-875, 1979.)
lasers. A knowledge of tracheal anatomy and
adherence to the principles of anesthesia and
tracheal surgery are necessary. Strictures involving
up to half the tracheal length can be resected and
anastomosed in more than 90 percent of patients.
Nevertheless, this method is contraindicated in the
following patients: when medical conditions are
judged too poor to tolerate an operation and when
predictable exacerbation of respiratory problems
would require prolonged and repeated intubation
and/or tracheostomy, such as in myasthenia gravis,
or in quadriplegia in which secretions cannot be con-
trolled.
The history and details of operative technique for
management of stenosis have been discussed.9'11 Of
crucial importance is the anesthesia of the stenotic
airway; deep halothane inhalation with oxygen al-
lows maintenance of spontaneous ventilation in-
traoperatively and allows more time for control of
the airway than is possible with an apneic pa-
tient.12 Surgical resection for postintubation stenosis
rarely is an emergency, except in patients with
stenosis immediately above the carina, where in-
tubation is difficult to maintain, and in patients
with hemmorhage secondary to tracheal-innominate
VOL. 87— NUMBER 8 AUGUST 1990
633
fistula. In almost all cases, as in our patient, it is
possible to perform endoscopic dilatation of the
lesion and, if necessary, intubate across the lesion
temporarily.13
Through a cervical exposure, up to 7 cm of the
tracheal length has been resected successfully. Re-
moving an insufficient amount of diseased trachea
may lead to recurrence of stenosis, but, ideally, at
least half of the ring below the cricoid should be
saved. The trachea then can sutured to the cricoid.
There must be good cartilaginous tissue and as little
inflammation as possible, but if the stenosis extends
to the subglottic larynx, the anterior larynx can be
resected in a sloping fashion to the inferoposterior
margin of the thyroid cartilage in an attempt to
preserve the usually nondiseased posterior cricoid
plate and its intimately related recurrent laryngeal
nerves.9,11 The trachea distal to the stricture usually
is normal, and care must be taken to avoid devas-
cularization during manipulation.
In 1986, Grillo reported 279 patients with post-
intubation stenosis who underwent reconstruction
and primary anastomosis.13 The results were classi-
fied as good (83 percent), satisfactory (9 percent),
and failure (4 percent) with a 1.8 percent mortality.
Complications were attributed to failure of diagnosis
or failure of technique. Failure of diagnosis included
failure to recognize an incompetent glottis before
resection, necessitating postresection intubation
and/or tracheostomy. Failure of technique included
excessive granulation (28 patients), separation (4
patients), stenosis (15 patients), and cord dys-
function (4 patients). No granulation at the suture
line occurred in 113 patients whose anastomoses
were done with absorbable sutures (Vicryl®). Sepa-
1. Andrews MJ, Pearson FG: Incidence and pathogene-
sis of tracheal injury following cuffed tube tracheostomy
with assisted ventilation: An analysis of two years’ pro-
spective study. Ann Surg 173:249-263, 1971.
2. Grillo HC, Cooper JD, Geffin B, et al.: A low-
pressure cuff for tracheostomy tube to minimize tracheal
injury. J Thorac Cardiovasc Surg 62:898-907, 1971.
3. Grillo HC: The trachea — tumors, strictures, and
tracheal collapse, in Glenn W, Thoracic and Cardio-
vascular Surgery, 4th Edition. Norwalk, CT, Appleton-
Century-Crofts, pp. 308-325, 1983.
4. Grillo HC: Benign and malignant disease of the
trachea, in Shields T, General Thoracic Surgery. 3rd
Edition. Philadelphia, PA, Lea & Febiger, pp. 667-679,
1989.
5. Lindholm CE: Prolonged endotracheal intubation.
Acta Anaesth Scand 33 (Suppl):l-30, 1970.
6. Cooper JD, Grillo HC: The evolution of tracheal in-
jury due to ventilatory assistance through cuffed tubes: A
pathological study. Ann Surg 169:334-338, 1969.
7. Weber AL, Grillo HC: Tracheal stenosis: An analysis
of 151 cases. Rad Clin NA 16(2): 291-308, 1978.
8. Andrews MJ, Pearson FG: An analysis of 59 cases of
ration and/or recurrent stenosis can be avoided by
careful attention to surgical technique to achieve a
tension-free anastomosis. Tension can be avoided by
using cervical flexion in all cases (chin to chest) and,
when necessary, sectioning the suprahyoid muscula-
ture (laryngeal release), as described by Montgom-
ery,14 or releasing the pulmonary hilum to obtain
additional length. Acute separation can be resutured
if it occurs early and necrosis has not yet taken
place. Delayed stenosis can be managed by dilata-
tion and/or stenting with a Montgomery® T-tube
followed by resection in four to six months to allow
resolution of inflammation.
Tracheal lesions also can be managed using the
Nd:YAG laser through the rigid bronchoscope and
under general anesthesia as reported in the
otolaryngology literature. Immediate results usually
are good following laser therapy but genuine tracheal
stenosis tends to recur following laser therapy.15 As
reported by Cavaliere, 81 patients treated for
tracheal stenosis with the laser endoscopically re-
quired 132 treatments, a stable result was achieved
in only 34 patients. Twenty patients required resec-
tion for recurrence.
CONCLUSION
Significant advances in tracheal surgery have
resulted in a better understanding of tracheal
pathology and improvements in surgical and
anesthetic techniques. Understanding the complica-
tions of intubation and/or tracheostomy facilitates
the diagnosis of tracheal stenosis. In over 90 percent
of patients, symptomatic tracheal stenosis can be
managed successfully by resection and primary
anastomosis. ■
tracheal stenosis following tracheostomy with cuffed tube
and assisted ventilation with special reference to diagnosis
and treatment. Br J Surg 60: 208-212, 1973.
9. Grillo HC: Surgical treatment of postintubation
tracheal injuries. J Thorac Cardiovasc Surg 78:860-875,
1979.
10. Grillo HC: Notes on the windpipe. Ann Thoracic
Surg 47:9-26, 1989.
11. Pearson FG, Cooper JD, Nelens JM, et al.: Primary
tracheal anastomosis after resection of the cricoid cartilage
with preservation of the recurrent laryngeal nerve. J
Thorac Cariovasc Surg 70:806-816, 1975.
12. Mathisen DJ, Grillo HC: Endoscopic relief of malig-
nant airway obstruction. Ann Thorac Surg 48:469-475,
1989.
13. Grillo HC, Zannini, P, Michelassi F: Complication
of tracheal reconstruction. J Thorac Cardiovasc Surg
91:322-328, 1986.
14. Montgomery WW: Suprahyoid release for tracheal
anastomosis. Arch Otolaryngol 99:255-260, 1974.
15. Cavaliere S, Foccoli P, Farina PL: Nd:YAG laser
bronchoscopy. A five-year experience with 1,396 appli-
cations in 1,000 patients. Chest 94:15-21, 1988.
634
NEW JERSEY MEDICINE
Kallmann’s Syndrome:
Reproductive Success
MICHAEL GOLDMAN, MD
ALBERT RIDDLE, MD
EUGENE MARKHAM, MD
Kallmann’s syndrome is a genetic disorder that includes pituitary
gonadotropin deficiency associated with sexual immaturity and infertility. A
successful treatment program resulted in normalization of sexual develop-
ment, spermatogenesis, and conception.
Kallmann’s syndrome (KS) is a congenital
disorder in which pituitary gonadotropins
are absent. This defect is thought to be
secondary to an idiopathic failure in gonadotropin-
releasing hormone (GnRH) from the hypothalamus;
it may be associated with other defects such as
anosmia, cleft lip, or cleft palate.12
Treatment of KS is directed toward restoring nor-
malization of gonadal steroid levels to allow sexual
maturation and to induce fertility.
From Englewood Hospital where Drs. Goldman and Rid-
dle are affiliated with the Department of Medicine and
Dr. Markham is affiliated with the Department of Ob-
stetrics/Gynecology. The paper was submitted in No-
vember 1989 and accepted in March 1990. Requests for
reprints may be addressed to Dr. Goldman, 600 Palisade
Avenue, Englewood Cliffs, NJ 07632.
The authors present a patient with KS to il-
lustrate a successful program of gonadal stimu-
lation, utilizing exogenous gonadotropins that cul-
minated in sexual maturation, normalization of
testosterone levels, initiation and completion of
spermatogenesis, and in a conception over a three-
year period.
CASE REPORT
The patient was referred for an infertility exami-
nation. He first was evaluated in 1970, at 19 years
of age. It was noted that the patient showed “poor
development of his genitalia” as well as a low normal
follicle-stimulating hormone (FSH) level. Bone age
showed a 2-year maturation delay. Skull x-rays were
normal. The patient received intramuscular testos-
terone injections for 4 years with subsequent
VOL. 87— NUMBER 8 AUGUST 1990
637
Table. Testosterone levels and semen analyses.
Date
Testosterone
Semen
No.
Volume
Motility
Morphology
Testes
Size
Comment
N1
300-1 OOOng/dl
xIO6
(cc)
(%)
(% normal)
(cm)
10/85
16
2 x 1
hCG begun
1/86
473
0
1.0
0
0
hMG begun
5/86
644
0
2.0
0
0
2Vz x 1
3/87
707
0
2.7
0
0
3x2
7/87
1.6
3.0
26
5
3V2 x 2
12/87
11.5
4.3
50
50
4/88
606
4.4
4.2
45
40
4x2
12/88
13.0
4.5
20
15
5/89
19.0
5
80
95
4V2 x 2V2
Good post-
coital test
6/89
+ Pregnancy test
2/90
Delivered 7 pound,
11 ounce
male
“growth of axillary and pubic hair.”
When seen in 1985, the patient had not received
hormonal therapy for over ten years. Medical his-
tory, except for pneumonia, was unremarkable. The
patient claimed to have erections with adequate sex-
ual satisfaction; he noted scant ejaculate. The pa-
tient shaved infrequently and did not notice body
hair growth since ending hormone injections. The
patient was unable to smell any common substances
such as tobacco, coffee, or peppermint, but could
“sense” toxic fumes, such as ammonia in high con-
centrations.
Family history revealed no reproductive problems.
Physical examination revealed an obese male,
eunuchoid in habitus, and looking much younger
than his 34 years of age. No facial defects were
noted. Mild gynecomastia was present bilaterally.
Testes were soft and each measured 2.1 cm. The
glans was normal in appearance but short, measur-
ing 7 cm when extended.
Laboratory data showed a normal T4, T3 resin, and
chemistry screen. Bone age was of a fully matured
male. Luteinizing hormone (LH) and FSH were 2.7
unit/L (normal < 18) and 6.3 unit/L (normal 5-25),
respectively. Testosterone levels and semen analyses
are noted in the Table for our patient from October
1985, to February 1990.
Therapy was begun with human chorionic
gonadotropin (hCG), 2,000 units intramuscularly,
three times per week. After three months of therapy,
and with normalization of testosterone levels,
human menopausal gonadotropin (hMG) was
NEW JERSEY MEDICINE
638
Abbreviations
KS: Kallmann’s syndrome
GnRH: Gonadotropin-releasing hormone
FSH: Follicle-stimulating hormone
LH: Luteinizing hormone
hCG: Human chorionic gonadotropin
hMG: Human menopausal gonadotropin
started at one ampule, three times per week along
with hCG.
The patient began to notice increasing hair
growth, and began to shave daily. Sexual function-
ing improved dramatically. Muscular strength in-
creased and his weight increased 25 pounds. His
voice also deepened. The volume of the testes in-
creased and the amount of ejaculate rose (Table).
Unfortunately, the patient also noted greying of his
hair and needed treatment for acne. A postcoital
test, in May 1989, was good and one month later a
conception in his partner was documented by a
positive pregnancy test. Pergonal® was stopped.
Pregnancy was uncomplicated, and resulted in the
vaginal delivery of a healthy 7 pound, 11 ounce male
infant at 38 weeks.
DISCUSSION
KS, an uncommon disorder seen in less than 1 in
10,000 males,1 2 3 has a constellation of symptoms, in-
cluding delayed sexual maturation and infertility
resulting from absent or diminished gonadotropins,
as well as an absence or impaired sense of smell
caused by a developmental defect in the olfactory
tracts. Lowered gonadotropins result from absent or
diminished GnRH. Studies have shown a continuum
of this defect, explaining the presence of measurable
levels of FSH and/or LH in some patients.4 5 Struc-
tural olfactory abnormalities have been confirmed in
vitro by autopsy studies and in vivo by magnetic
resonance imaging, demonstrating hypoplasia or
aplasia of the rhinencephalon.4 Midline defects, in-
cluding cleft lip and palate, also may be seen.
The proximity of the olfactory centers, with the
hypothalamic tract responsible for GnRH, suggests
a common unifying defect. Indeed, animal studies
have shown that hypothalamic GnRH-producing
neurons originate in the olfactory placode and that
a defect in their migration from this area could ac-
count for this dual disorder.6 Genetic analysis of the
human gene encoding GnRH (located to the short
arm of chromosome8) has failed to demonstrate de-
letions or major rearrangement as a common basis
for KS.7
Genetic transmission of this disorder is uncertain,
but probably is autosomally transmitted.
Treatment of KS is directed towards the desires
and needs of the patient. Delayed maturation simply
can be treated by testosterone or estrogen replace-
ment. More physiologic is the use of exogenous
GnRH or the pituitary hormones hMG and hCG.
These hormones may stimulate gonadal function
and, thereby, will produce both endogenous
testosterone or estrogen and stimulate spermato-
genesis or oogenesis necessary for infertile patients.
Progressive increase in testicular volume, as demon-
strated in our patient usually indicates successful
treatment.8 The olfactory defects remain permanent
and untreatable.
In our patient, the finding is noteworthy that
semen parameters never normalized despite success-
ful sperm production and the ability to conceive.
This is consistent with other studies with KS that
show reproductive success with sperm numbers well
below normal ranges.9 It is uncertain why further
increases in sperm production are not seen. ■
REFERENCES
1. Lieblich JM, Rogol AD, White BJ, Rosen SW: Syn-
drome of anosmia with hypogonadotropic hypogonadism
(Kallmann’s syndrome). Am J Med 73:506-519, 1982.
2. Kallmann F, Schoenfeld W, Barrera S: The genetic
aspect of primary eunuchoidism. Am J Merit Defic
48:203-236, 1944.
3. Jones JR, Kemmann E: Olfacto-genital dysplasia in
the female. Obstet Gynecol Annu 5:443, 1976.
4. Yeh J, Rebar R, Liu J, Yen S: Pituitary function in
isolated gonadotropin deficiency. Clin Endocrinol 31:375,
1989.
5. Klingmuller D, Dewes W, Krahe T, et al.: Magnetic
resonance imaging with anosmia and hypothalamic
hypogonadism (Kallmann’s syndrome). J Clin Endocrinol
Metab 65:581, 1987.
6. Schwanzel-Fukuda M, Pfaff DW: Origin of luteiniz-
ing hormone-releasing hormone neurons. Nature 338:161-
164, 1989.
7. Weiss J, Crowley W, Jameson J: Normal structure
of the gonadotropin-releasing hormone (GnRH) gene in
patients with GnRH deficiency and idiopathic hypo-
gonadotropic hypogonadism. J Clin Endocrinol Metab
69:299, 1989.
8. Ley S, Leonard J: Male hypogonadotropic hypo-
gonadism: Factors influencing response to human
chorionic gonadotropin and human menopausal
gonadotropin, including prior exogenous androgens. J Clin
Endocrinol Metab 61:746, 1985.
9. Opperman D, Happ J, Mayr W: Stimulation of
spermatogenesis and biological paternity by intranasal
(low dose) gonadotropin-releasing hormone (GnRH) in a
male with Kallmann’s syndrome: Intraindividual com-
parison of GnRH and gonadotropins for stimulation of
spermatogenesis. J Clin Endocrinol Metab 65:1060, 1987.
VOL. 87— NUMBER 8 AUGUST 1990
639
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640
NEW JERSEY MEDICINE
Clinical Decision
Making
Conference on Therapeutic and Diagnostic Options
HOWARD HOLTZ, MD
ROBERT RESTIFO, DO
A 66-year-old woman was diagnosed with small cell carcinoma of the lung.
Different opinions on management led to critical appraisal of therapy litera-
ture and a treatment decision.
A66-year-old woman was admitted to
UMDNJ-University Hospital, Newark, for
the management of a lung mass.
Robert Restifo, DO: The patient was well until
three months earlier when she presented with com-
plaints of fever, shortness of breath, and blood-
streaked sputum. A right lower lobe pneumonia was
diagnosed, and she was given a course of antibiotics.
The patient improved symptomatically but a repeat
chest x-ray one month later revealed persistence of
the right lower lobe infiltrate. A computerized tomo-
Dr. Holtz is affiliated with the Division of General Medi-
cine, UMDNJ-New Jersey Medical School, and Dr.
Restifo is a senior fellow in pulmonary disease, UMDNJ-
New Jersey Medical School, Newark. Requests for re-
prints may be addressed to Dr. Holtz, UMDNJ-University
Hospital, Room 1246, 150 Bergen Street, Newark, NJ
07103-2757.
graphic (CT) study of the chest was ordered and the
patient was referred to the Division of Pulmonary
Medicine. The study showed a right lower lobe mass
extending to the pleura with no evidence of
lymphadenopathy; fiberoptic bronchoscopy was
scheduled.
The patient, a housekeeper, suffered from asthma
since childhood; in her adult life, the asthma was
easily controlled. She had uncomplicated pneu-
monia at age 63; a colon resection at age 36 for
reasons that were unclear; and a hysterectomy at age
30 for recurrent uterine bleeding. There were no
known allergies. She was being treated with an oral
theophylline preparation and an inhaled beta-
agonist. She smoked one pack of cigarettes per day
for 36 years; however, she discontinued smoking 10
years prior to her current illness. There was no his-
tory of alcohol or drug use. Her mother had a history
of hypertension and heart disease.
VOL. 87— NUMBER 8 AUGUST 1990
641
CLINICAL DECISION MAKING
The patient’s temperature was 98°F; pulse was 80;
and respirations were 18. Blood pressure was 120/74
mm Hg. On examination, the patient was alert and
oriented; the skin was cool and dry, and the head
was normal. The neck was supple, the carotid pulses
were full, and no bruits were appreciated. No
lymphadenopathy was found. Auscultation of the
heart revealed a regular rhythm with a grade 2/6
systolic ejection murmur. Decreased breath sounds
were noted at the right lung base. Examination of
the abdomen revealed an intact and functioning
colostomy without enlargement of the liver or
spleen. There was no peripheral edema, clubbing, or
cyanosis. Rectal examination was normal and stool
gave a negative test for occult blood. Neurologic
examination was normal.
Laboratory data revealed the following: white
blood cell count, 3,100; hematocrit, 35.3 percent;
platelet count, 429,000; prothrombin time and
partial thromboplastin time, normal; urea nitrogen,
9 mg/dL; creatinine, 1.0 mg/dL; sodium, 139 mmol;
potassium, 4.8 mmol; chloride, 104 mmol; carbon
dioxide, 28 mmol; blood glucose, 140 mg/dL; serum
calcium, 9.3 mg/dL; serum aspartate aminotrans-
ferase, 26 LI; alkaline phosphatase, 81 U; and uri-
nalysis, normal. An electrocardiogram revealed a
normal sinus rhythm at a rate of 80. An x-ray film
of the chest disclosed a large density in the right
lower lobe without hilar or mediastinal enlargement.
Fiberoptic bronchoscopy revealed an endo-
bronchial lesion obstructing the right lower lobe
bronchus distal to the opening of the superior seg-
ment bronchus. Biopsy of the lesion was reported as
small cell carcinoma (SCCL), intermediate cell
type.
Repeat chest CT showed no interval change. A CT
scan of the head and abdomen did not reveal
metastatic disease. Bilateral bone marrow aspira-
tion and biopsies were normal.
Howard Holtz, MD: This case was chosen because
of the diametrically opposed consultative opinions
on therapy for this patient with SCCL. The medical
team and oncologists recommended chemotherapy
and radiation; the thoracic surgeons suggested in-
itial resection of the tumor followed by these
therapies.
SCCL accounts for 15 percent of all lung cancers;
15 percent are “limited” on presentation and the
median survival with therapy in those with limited
disease is 15 months. Also, due to the extremely fast
doubling time and efficient lymphatic and
hematogenous dissemination of SCCL, its early
micrometastasis renders the surgeon’s knife impo-
tent. While surgery is the only chance for cure in the
non-small cell lung cancers, in small cell tumors it
has taken a back seat to a temporary and toxic
victory with antineoplastic agents and radiation.
One need not apply the tumor-nodal metastasis
(TNM) staging system to SCCL because of the inef-
ficacy of surgery. Limited disease is tumor limited
to one hemithorax including the ipsilateral scalene
or supraclavicular nodes and extensive disease is
anything else.1 This simple staging system is suffi-
cient to predict different response rates and
prognoses, but clearly excludes any consideration of
surgery.
The surgeon’s recommendation in this case
prompted an examination of evidence supporting
the teaching of SCCL as a nonsurgical disease.
Clinical suspicion of the futility of surgery for this
disease began to evolve into certainty in 1969. That
year, the Medical Research Council (MRC) of Great
Britain published a comparative trial of surgery and
radiation therapy.2 The study randomized 144 pa-
tients with SCCL diagnosed preoperatively who
were candidates for curative resections. Seventy-one
patients were randomized to surgery and 73 patients
were randomized to radiotherapy. The five-year
survival was 1 percent in the surgical group and 4
percent in the radiotherapy group. In addition, 62
percent of the surgical group eventually required
additional therapy (predominantly radiotherapy).
The mean survival for surgical patients was 199 days
versus 284 days in the radiotherapy group (P=.05).
There were 5 patient deaths attributed to surgery
and the postoperative surgical survival curve re-
vealed more deaths in the early followup than the
radiotherapy group. The ten-year followup of these
patients revealed no survivors in the surgical group
and 3 patients who were alive in the radiotherapy
group.1 The mean survival was 199 days and 300
days for the surgical and radiotherapy groups, re-
spectively, now reaching statistical significance at
P=.04. Using a methodologic hierarchy for therapy
recommendations (Table), the level 1 MRC trial
supports grade A advice not to operate.4
In addition to this randomized comparative trial,
other evidence contributed to the demise of surgery
in SCCL. In 1973, patients with SCCL who died
within 30 days of operation for curative resection
were studied.5 At autopsy, 70 percent had residual
disease, predominantly distant metastases. Finally,
Mountain’s series of over 2,000 lung cancer patients
showed no long-term survivors with small cell his-
tology;6 data indicated that survival in SCCL had
no correlation with anatomic extent of disease, and
Mountain concluded that the biologic behavior of
SCCL warranted automatic assignment of patients
to the worst clinical stage. Thus, the use of the TNM
staging of non-small cell lung cancers, primarily to
determine resectability and the continued use of lim-
ited versus extensive staging in SCCL was started.
Why would some surgeons challenge the grade A
recommendation not to operate on SCCL? The
642
NEW JERSEY MEDICINE
CLINICAL DECISION MAKING
Table. Grades of therapeutic recommendations.
Grade A: Level I Evidence. The best quality of therapeutic evidence is the randomized
controlled trial (RCT) with a low alpha (false positive) error in a trial that showed a positive
therapeutic effect or a low beta (false negative) error in a negative trial. The extent of alpha
error is easy to obtain; it is the same as the P value reported in the trial. For example, a
randomized trial reveals drug A to be superior to placebo in decreasing mortality at a P value
< .001. This positive therapeutic effect has a very small probability of being due to chance
alone, less than 1 in a 1,000. A level I negative trial shows no therapeutic benefit and has
a low probability of being a false negative result (beta error). A study with a low beta error
is sometimes referred to as having high power: a high likelihood of detecting a therapeutic
difference.
Grade B: Level II Evidence. These studies are RCTs with higher than typically accepted alpha
or beta errors. Conventionally accepted errors are .05 alpha and .20 beta. For example, a
randomized trial showing surgery improved survival at a P value of .08 would constitute level
II evidence supporting the surgical therapy. A negative trial with a high beta error (low power)
also would be in this category. For example, an RCT showing no benefit of drug A but having
a beta error of 0.40 would constitute level II evidence against using drug A. The 40 percent
beta error indicates the study only had a 60 percent chance of detecting a therapeutic benefit,
i.e. the study had low power. Meta-analyses often are used with this level of evidence. By
combining the results of smaller individual trials addressing the same hypothesis, these
analyses attempt to increase the power and determine if conventional levels of significance
are reached.
Grade C: Levels III, IV, and V Evidence. These studies are not randomized. Therefore,
patients do not have an equal and random chance of being assigned to the treatment and
control groups. Level III studies compare patients who received a particular therapy with
contemporaneous patients who did not, while level IV studies utilize historical comparisons.
Level V studies are case series reflecting the experience of a group of patients receiving a
particular therapy without any associated control group.
reason is that methodologic ranking of evidence is
essential in assessing the validity of a study, but is
not helpful in evaluating its applicability. It is this
feature of the MRC trial that has been most criti-
cized, that is, the MRC trial was robust evidence
against surgery 20 years ago, but is an anachronism
in 1990. The question today is not whether surgery
is a beneficial single therapy for SCCL but whether
surgery is a useful initial therapy (in highly selected
patients) followed by adjunct chemotherapy and
radiation. Effective chemotherapeutic regimens had
not yet been discovered at the time this study was
performed. In addition, many patients were un-
doubtedly considered operable in the MRC trial de-
spite having metastatic lesions that would be de-
tected with the sophisticated imaging studies avail-
able today. The MRC study only included patients
whose tumors could be reached with a rigid
bronchoscope. These centrally located cancers do
worse with surgery than more peripherally located
tumors. In addition, the operations in the MRC
study were pneumonectomies and subsequent stud-
ies have confirmed that patients undergoing lobec-
tomies or segmental resections have better out-
comes. Furthermore, the extent of intrathoracic dis-
ease was not described and 41 percent of the patients
who underwent surgery had tumors that were not
resectable at operation. It is likely, therefore, that
many MRC patients from 1969 would not be con-
sidered surgical candidates by thoracic surgeons
in 1990.
The rationale for operating on patients with very
early stages of disease was bolstered by the develop-
ment of effective oncologic regimens that could be
employed postoperatively. In addition, it was known
that recurrence, in patients who had responded to
oncologic regimens, occurred in the chest in a ma-
jority of patients. The Veterans Administration re-
port of asymptomatic pulmonary nodules included
11 SCCL.7 These patients had virtually the same
survival experience as study patients who had non-
small cell bronchogenic carcinomas: a one-year
survival of 64 percent and a five-year survival of 36
percent. The number of cases in this study was small
and the clinical scenario atypical, considering the
asymptomatic presentation and peripheral location
of most tumors. However, the study demonstrated
that selected patients with SCCL can experience
long-term survival after surgery.
A cooperative trial in 1989 employed initial
surgical resection in 112 patients with SCCL fol-
lowed by randomization to two chemotherapeutic
regimens.8 Sixty-five patients were diagnosed post-
operatively. Favorable early survival curves (two-
year survival was 76 percent in stage I) correlated
with pathologic TNM stage.
Based on studies,916 some experts are recommend-
ing initial resection for very limited SCCL when
\/ni A7— MIIMRFR ft AUGUST 1 QQfl
Ml
CLINICAL DECISION MAKING
there is no evidence of metastasis (including
mediastinal exploration), followed by adjuvant
chemotherapy and radiotherapy. Unfortunately,
none of these studies tested the hypothesis: surgery
improves survival in highly selected patients with
SCCL. Therefore, the evidence supporting this po-
sition is subexperimental or experiential (grade C).
The survival curves in these studies may be seduc-
tive but have been “doctored” with biases analogous
to what skilled plastic surgeons can do to reshape
the body’s curves. A majority of the patients in these
studies were diagnosed postoperatively with SCCL.
Thus, in many cases the survival of a patient with
an asymptomatic pulmonary nodule has been com-
pared to a symptomatic patient diagnosed pre-
operatively. The prognoses of these patients are very
likely different, regardless of therapy.
Matching historical or cohort “controls” without
randomization does not resolve the selection bias.
Anatomic staging after surgery frequently advances
the stage. Therefore, a patient whose clinical stage
is I or II is apt to be a stage II or III postoperatively.
Consequently, the subexperimental evidence com-
pares patients with very early disease in surgical
groups with more advanced patients treated conven-
tionally and, by definition, staged clinically. Pa-
tients nonrandomly selected for surgery also may
have better functional ability than nonsurgical com-
parisons; and functional status, generally un-
reported in these studies, is an independent predic-
tor of survival in lung cancer.17 In addition, patients
chosen for surgery are more likely to have less co-
morbidity than those treated conventionally, which
contributes to the overzealous attributions to
surgical efficacy. Finally, excluding perioperative
death from survival analyses comes close to saying
you did not chop down the cherry tree.
The evidence does not support the routine rec-
ommendation for surgery in the infrequent patient
with very limited SCCL. It might be argued that
physicians often make recommendations with
“grade C” evidence after a careful consideration of
the potential benefits and risks in an individual pa-
tient. Yet, recent reports of prolonged survival18 in
conventionally treated patients with very limited
SCCL add further support to the continued
nonsurgical approach to this disease. I would hope
those who do recommend surgery for SCCL produce
a truly informed consent reflecting the subex-
perimental nature of the clinical evidence for
surgical intervention. Additional requisites should
be a negative mediastinal exploration and planned
resection with a lobectomy or lesser procedure.
Robert Restifo, DO: The treatment plan for our
patient was conventional chemotherapy and radi-
ation. One month later, the oncologist discovered a
small metastsis suggesting the disease was dis-
seminated on presentation. She had a partial
response to therapy and died 14 months after
diagnosis. ■
REFERENCES
1. Hyde L, Yee J, Wilson R, Patino ME: Cell types and
the natural history of lung cancer. JAMA 193:52-54, 1965.
2. Miller AB, Fox W, Tall, R: Five-year followup of the
Medical Research Council comparative trial of surgery
and radiotherapy for the primary treatment of small or oat
cell carcinoma of the bronchus. Lancet 2:501-505, 1969.
3. Fox W, Scadding JG: Medical Research Council
comparative trial of surgery and radiotherapy for primary
treatment of small celled or oat celled carcinoma of the
bronchus: Ten-year followup. Lancet 2:63-65, 1973.
4. Sackett DL: Rules of evidence and clinical rec-
ommendations on the use of antithrombotic agents. Chest
89, 2:25-35, 1986.
5. Matthews MJ, Kanhouwa S, Pickren J, Robinette D:
Frequency of residual and metastatic tumor in patients
undergoing curative surgical resection for lung cancer.
Cancer Chemother Rep 4:63-67, 1973.
6. Mountain CF, Carr DT, Anderson WAD: A system
for the clinical staging of lung cancer. AJR 120:130-138,
1974.
7. Higgins GA, Shields TW, Keehn RJ: The solitary
pulmonary nodule: Ten-year followup of Veterans Admin-
istration Armed Forces Cooperative Study. Arch Surg
110:570-575, 1975.
8. Karrer K, Shields TW, Denck H, et ah: The impor-
tance of surgical and multimodality treatment for small
cell bronchial carcinoma. J Thorac Cardiovasc Surg
97:168-176, 1989.
9. Bates M, Hurt R, Levison V, Sutton M: Treatment
of oat cell carcinoma of bronchus by preoperative radio-
therapy and surgery. Lancet 1:1134-1135, 1974.
10. Shore DF, Paneth M: Survival after resection of
small cell carcinoma of the bronchus. Thorax 35:819-822,
1980.
11. Shields TW, Higgins GA, Matthews MJ, Keehn RJ:
Surgical resection in the management of small cell
carcinoma of the lung. J Thorac Cardiovasc Surg
84:481-488, 1982.
12. Davis S, Wright PW, Shulman SF, et ah: Long-term
survival in small cell carcinoma of the lung: A population
experience. J Clin Oncol 3:80-91, 1985.
13. Meyer JA: Five-year survival in treated stage I and
II small cell carcinoma of the lung. Ann Thoracic Surgery
42:669-688, 1986.
14. Friess GG, McCracken JD, Troxell ML, et ah: Ef-
fect of initial resection of small cell carcinoma of the lung:
A review of Southwest Oncology Group Study 7628. J Clin
Oncol 3:964-968, 1985.
15. Ohta M, Hara N, Ichinose Y, et ah: The role of
surgical resection in management of small cell carcinoma
of the lung. Jpn J Clin Oncol 10:289-96, 1986.
16. Shepherd FA, Evans WK, Feld R, et ah: Adjuvant
chemotherapy following surgical resection for small cell
carcinoma of the lung. J Clin Oncol 6:832-838, 1988.
17. Pater JL, Loeb M: Nonanatomic prognostic
analysis. Cancer 50:326-331, 1982.
18. Shepherd FA, Ginsberg R, Evans WK, et ah: “Very
limited" small cell lung cancer (SCLC) — results of
nonsurgical treatment. Proc Am Soc Clin Oncol 3:223,
1984 (abstr C-870).
644
NEW JERSEY MEDICINE
Thrombolytic Therapy
in the Presence of Gastrointestinal Bleeding
NICHOLAS J. SCHNEEMAN, MD
ELLIOTT M. STEIN, MD
This case report describes an appropriate exception to well-known contrain-
dications of the use of thrombolytic therapy including a brief discussion
regarding the use of thrombolytic agents in pulmonary embolism and the
hemorrhagic events associated with them.
Hemorrhagic complications of thrombolytic
therapy are well described in the medical
literature.1'3 Concerns regarding these com-
plications have led to the development of relative
and absolute contraindications to thrombolytic ther-
apy. We present a case of massive pulmonary em-
bolism treated successfully with streptokinase in the
presence of gastrointestinal (GI) bleeding, a remote
history of reversible ischemic neurologic deficit
(RIND), and advanced age.
Dr. Schneeman is chief resident in family practice, Over-
look Hospital, and Dr. Stein is attending physician,
Division of Cardiology, Overlook Hospital, Summit. The
manuscript was submitted in February 1990 and ac-
cepted in April 1990. Requests for reprints may be ad-
dressed to Dr. Schneeman, 20 Upper Overlook Road,
Summit, NJ 07901.
CASE REPORT
An 83-year-old, vigorous white female was ad-
mitted to our hospital for a profound hypochromic,
microcytic anemia, (HG, 6.6; MCV, 75.4). Two years
previously, the patient started aspirin therapy due
to a RIND. On admission, stools were guaiac positive
and iron studies supported the diagnosis of iron defi-
cient anemia. A gastrointestinal workup (including
an upper GI series, small-bowel follow through, and
colonoscopy) was normal. Aspirin was discontinued.
The patient was transfused and hemoglobin (HG)
stabilized at 10.9. Hospitalization was extended to
ten days due to a localized phlebitis and cellulitis
of the left arm.
Two days after discharge, the patient was seen in
the emergency room with sudden onset of in-
VOL. 87— NUMBER 8 AUGUST 1990
645
capacitating dyspnea. Severe hypoxia on 100 percent
oxygen (PO250), clear lung fields, and an un-
remarkable chest x-ray suggested the diagnosis of
pulmonary embolism. Confirmation was obtained
by a technetium-99 perfusion lung scan demonstrat-
ing virtually no filling of the left lung and multiple
defects in the right lung (Figure 1). The patient was
intubated and placed on assisted mechanical ven-
tilation. Despite this, she became more hypoxic
(P0238 on 100 percent 02) and tachycardic (HR,
120). The patient’s hemoglobin had not fallen since
the previous admission; however, the rectal exami-
failure and very recent or active lower GI bleeding.
After consultations with a vascular surgeon,
gastroenterologist, and the patient’s family, throm-
bolytic therapy was instituted via a Swan-Ganz
catheter. A bolus of 250,000 units of streptokinase
was given into the pulmonary artery over 30
minutes. Ten minutes after the infusion began, there
was evidence of clot lysis: the pulmonary artery
diastolic pressure decreased from 40 mm Hg to 15
mm Hg with a simultaneous decrease in heart rate
from 120 beats/min to 80 beats/min. However, the
patient became more hypotensive with a systolic
When both the potential risks and benefits of a prescribed treatment
are so greatly augmented, as in this case, it becomes difficult to be
sure one is adhering to the “primum non nocere” principle. We do not
take this principle lightly.
nation revealed dark, loose, guaiac positive stool.
The nasogastric aspirate was guaiac negative. The
total elapsed time since onset of symptoms was ap-
proximately four hours and the working diagnoses
were massive pulmonary embolism with respiratory
blood pressure of 60 mm Hg. Arterial blood gases
revealed a severe metabolic acidosis but markedly
improved oxygenation (PO2100). Aggressive fluid,
vasopressor, and ventilatory management resulted
in hemodynamic stability within two hours. A main-
646
NEW JERSEY MEDICINE
tenance dosage of 100,000 units of streptokinase was
infused over the next 24 hours and then standard
heparin therapy was initiated. The stools remained
guaiac positive but the hemoglobin did not drop.
A repeat perfusion scan was obtained 36 hours
after the initial scan (Figure 2). There was dramati-
cally increased perfusion of the left lung and some
increase in the right lung. After obtaining negative
aortoiliac and lower extremity sonograms, a Green-
field vena cava filter was placed transvenously on
the fourth day of hospitalization. Anticoagulation
therapy was changed to a three-month course of low-
dose warfarin. Six months after discharge, the pa-
tient was found to have no appreciable morbidity
from the pulmonary embolism.
DISCUSSION
Attention to primary prevention and early detec-
tion of thrombophlebitis, coincident with aggressive
secondary medical management, brought about a
decrease in pulmonary embolism mortality between
1970 and 1985/ Continued improvement in man-
aging this condition may come from the use of
thrombolytic agents. Although specific indications
for their use in pulmonary embolism have not been
established clearly, many sources advocate the use
of thrombolytic agents in massive pulmonary em-
bolism.1 2 3-56 Not only do these cases demonstrate high-
er mortality, but morbidity is exacerbated by large
loss of functional lung tissue and the development
of pulmonary hypertension. When given early in the
course of massive pulmonary embolism, throm-
bolytic agents have been extremely effective in
promoting clot lysis, increasing lung capillary vol-
ume, and reversing pulmonary hypertension.2
Another potential benefit is the eradication of re-
sidual thrombus in the deep veins.
Unfortunately, hemorrhagic events associated
with thrombolytic use are not rare. One study found
27 of 167 patients required blood transfusions after
using either urokinase or streptokinase for
pulmonary embolism.1 Vessel wall damage seems to
be the most important etiologic factor. Indeed,
catheterization sites for invasive procedures are the
principle source of bleeding in all studies.2 5 Thus,
conditions that predispose to vascular injury, rather
than coagulation abnormalities, appear to carry
higher risk. Published lists of contraindications to
thrombolytic therapy bear this out. Active internal
bleeding, recent stroke, or other active intracranial
processes are regarded as absolute contraindica-
tions. Relative contraindications include uncon-
trolled hypertension or recent surgery, vessel punc-
ture, obstetrical delivery, gastrointestinal bleeding,
and trauma. There are numerous minor contrain-
dications including age greater than 75/
Our patient suffered a massive pulmonary em-
bolism and continued to be severely hypoxic and
tachycardic despite maximal support. Invasive
monitoring demonstrated impressive pulmonary hy-
pertension. There also was evidence of very recent
or active GI bleeding. Without further intervention,
however, we felt death from acute respiratory failure
was inevitable. Heparin therapy alone, while having
a lower risk of hemorrhage, would not have changed
her prognosis. At best, heparin therapy would only
prevent further embolic events. Therefore, we de-
cided to use thrombolytic therapy even though the
patient had recognized contraindications.
The method of administration was the full dose
streptokinase protocol approved for pulmonary em-
bolism in our institution. Another regimen described
in the literature involves administering low-dose
streptokinase (10-20,000 units/hour) in combination
with heparin.8 Discontinuing the streptokinase after
evidence of clot lysis was another option. These are
alternative approaches that may not provide the
same continued local and systemic benefits of full
dose thrombolytic therapy.
The decision to use streptokinase in this patient
violated many published lists of absolute and rela-
tive contraindications to thrombolytic therapy. Yet
the patient was in great need. When both the poten-
tial risks and benefits of a prescribed treatment are
so greatly augmented, as they were in this case, it
becomes difficult to be sure one is adhering to the
“primum non nocere” principle. We do not take this
principle lightly nor do we advocate a more cavalier
approach to the use of thrombolytic therapy. How-
ever, extreme circumstances require extreme mea-
sures. We present this case to illustrate an ap-
propriate exception to well-known guidelines. ■
REFERENCES
1. Cooperative Study: Urokinase-streptokinase em-
bolism trial, phase 2 results. JAMA 229: 1606-1613, 1974.
2. Marder VJ, Sherry S: Thrombolytic therapy: Cur-
rent status. N Engl J Med 318: 1512-1520, 1988.
3. Marder VJ, Sherry S: Thrombolytic therapy: Cur-
rent status. N Engl J Med 318: 1585-1595, 1988.
4. Gillum RF: Pulmonary embolism and throm-
bophlebitis in the United States, 1970-1988. Am Heart J
114: 1262-1264, 1987.
5. Trulock EP: Approaches to deep venous thrombosis
and pulmonary embolism in aging patients. Geriatrics 43:
101-113, 1988.
6. Wenger NK: Pulmonary embolism. Postgraduate
Medicine 84: 107-115, 1988.
7. National Institutes of Health Consensus Develop-
ment Conference: Thrombolytic therapy in thrombosis.
Ann Intern Med 93: 141-144, 1980.
8. Leeper KV Jr, Popovich A: Treatment of massive
acute pulmonary embolism and low-dose streptokinase
and heparin. Chest 93: 234-240, 1988.
VOI R7_ NUMRFR fi AllfitlST 1QQO
647
Pelvic Papillary
Neoplasia
Along the Round Ligament Simulating Inguinal Hernia
BERNARD PEISON, MD
BARRY BENSSCH, MD
ANTHONY TONZOLA, MD
Papillary serous adenocarcinoma along the round ligament in a female is
not invariably metastatic from the ovary , but may arise de novo from the
multipotential pelvic peritoneum; it may mimic an inguinal hernia.
A59-year-old woman was admitted to
Rahway Hospital in August 1987, for repair
of an incarcerated right inguinal hernia.
During surgical exploration of the inguinal canal,
the round ligament was identified with a tumor mass
attached to it. Frozen section diagnosis was
“papillary adenocarcinoma, probably metastatic.”
Histological examination of the tumor revealed skel-
etal muscle and adipose tissue infiltrated with large
nests of mucin-producing papillary serous adenocar-
cinoma showing psammoma bodies that suggested
a metastasis from a primary ovarian neoplasm (Fig-
ure). Following removal of the tumor, extensive
clinical evaluation (gallium scan, computed tomog-
raphy (CT) scan, thyroid scan, and mammogram)
was normal. Past medical history included an ab-
From Rahway Hospital, where Drs. Peison and Benisch
are affiliated with the Department of Pathology and Dr.
Tonzola is affiliated with the Department of Surgery. This
manuscript was submitted in December 1989 and ac-
cepted in March 1990. Requests for reprints may be
addressed to Dr. Peison, Rahway Hospital, 865 Stone
Street, Rahway, NJ 07065.
dominal hysterectomy and bilateral salpingo-
oophorectomy in 1984 because of uterine bleeding.
The uterus showed multiple leiomyomata and ex-
tensive adenomyosis. Both ovaries and Fallopian
tubes were grossly normal and histologically benign.
The patient was readmitted a year later because
of a recurrent mass in the right groin area. At sur-
gery, a tubular segment of indurated skeletal muscle
and adipose tissue measuring 11 x 4 x 3 cm was
removed. Gross inspection revealed most of the
specimen to be replaced by a partially cystic sero-
mucinous tumor. In addition, suture material from
previous surgery was identified. Histological exam-
ination revealed skeletal muscle to be largely in-
filtrated by papillary serous adenocarcinoma with
heavily calcified psammoma bodies. A single iliac
lymph node was free of tumor. The patient had a
recurrence of the tumor in May 1989, and presently
is being treated with Cytoxan® and cisplatin.
DISCUSSION
Tumors of the round ligament are rare; they may
be benign or malignant, primary or metastatic.1
648
NEW JERSEY MEDICINE
Figure. Papillary serous adenocarcinoma arising along the
round ligament in a 59-year-old female patient (hematoxylin and
eosion x 20).
Some lesions may arise from adjacent embryonic
mesonephric structures related to endometriosis or
from the mesothelium. The latter usually are
papillary serous adenocarcinomas. While the peri-
toneum is a frequent site of metastatic tumor, pri-
mary neoplasms are rare. However, there is a small
group of primary papillary tumors of the peritoneum
that differs significantly from the usual diffuse
mesothelioma of papillary type, overlaps with the
microscopic morphology of ovarian papillary serous
carcinoma, and appears to be derived from extra-
ovarian mesothelium of mullerian origin.2
Peritoneal papillary carcinoma is a rare tumor
that has a predilection for the pelvic peritoneum in
women. Histologically, peritoneal papillary
carcinoma is identical to ovarian papillary serous
carcinoma, but either spares or only microscopically
involves the surface of the ovaries. The absence,
however, of a primary ovarian neoplasm must be
ruled out by careful evaluation of the internal geni-
talia, pelvis, and peritoneal cavity.
Peritoneal papillary serous tumors have been
noted in the literature for over 30 years.3 However,
these tumors received little attention until 1977,
when Kannerstein et aid reported 15 cases and
emphasized the need for separating extra-ovarian
serous papillary carcinoma from malignant
mesothelioma. Although no single feature is of
absolute differential diagnostic value, the presence
of columnar tumor cells, psammoma bodies, and
epithelial mucin, and the absence of hyaluronic acid
favor the diagnosis of papillary carcinoma rather
than mesothelioma.
Immunohistochemical techniques appear to in-
dicate that mesothelioma stains intensely with
keratin antisera and weakly or negatively with
carcinoembryonic antigen (CEA) antisera, while
adenocarcinoma stains intensely with CEA antisera
and weakly or negatively with keratin antisera.5
Ulbright et al. described a retroperitoneal
neoplasm in an 11-year-old girl with a microscopic
appearance identical to that of papillary serous
carcinoma of ovary.6 There was no evidence of
ovarian involvement. Immunohistochemical stain-
ing for amylase was positive within the cytoplasm
of tumor cells. Since amylase is a marker for serous
ovarian tumors, this finding supports the belief that
ovarian-type neoplasms that occur at ectopic lo-
cations essentially are identical to their ovarian
counterpart.
Extra-ovarian serous carcinoma is a rare lesion as
compared with the usual ovarian serous tumors. In
focal extra-ovarian serous carcinoma, the peritoneal
surfaces of the female genital organs are studded
with tumor resembling ovarian serous carcinoma,
while the ovarian parenchyma either is spared or
only minimally involved.7 By light microscopy, these
tumors share many of the histopathological features
of serous ovarian carcinoma and were regarded as
ovarian carcinoma with widespread metastases.
Gooneratne et al. studied 16 cases from two in-
stitutions, and felt these tumors were distinct and
should be separated from the usual serous papillary
carcinoma." However, Gooneratne did favor origin
from ovarian surface epithelium rather than
mesothelium and used the terminology of “serous
surface papillary carcinoma’’ for this tumor. It now
is accepted that the ovarian surface (germinal)
epithelium is derived from the basic coelomic
epithelium or mesothelium.
Four of Gooneratne’s cases had coexisting second
primary neoplasms, three cases had carcinoma of
the endometrium, and one case had endometrioid
carcinoma of the ovary. The survival of the patients
was shorter than that of patients with ovarian serous
papillary carcinoma of the same grade without
predominant surface involvement.
Kannerstein et al. also concluded that these
lesions should not be classified as mesotheliomas,
especially since this might imply similarities in
etiology and treatment.4 During a study of 25 peri-
toneal papillary tumors in women, Foyle et al. found
these tumors exhibited a wide range of morphology,
from well-differentiated mesothelial proliferations to
neoplasms with morphologic characteristics of mul-
tiple focal extra-ovarian serous carcinoma.2 Foyle
suggested these tumors were derived from
mesothelium and should be termed “extra-ovarian
serous papillary carcinomas.” Mills et al. compared
the biologic behavior of 10 patients with serous sur-
face papillary carcinoma to a control group of 16
patients with serous ovarian papillary carcinoma,
and found serous surface papillary carcinoma had a
significantly worse prognosis than serous ovarian
papillary carcinoma.9 Four patients had coexistent,
nonperitoneal, mullerian-type carcinomas.
VOL. 87— NUMBER 8 AUGUST 1990
649
The relationship between serous proliferations of
the ovary and histologically identical lesions of the
peritoneum is complex. When an ovary contains in-
traparenchymal serous carcinoma and carcinoma-
tous foci involve the peritoneum, the latter conven-
tionally are considered metastases. This viewpoint
cannot be applied, however, when a clearcut ovarian
carcinoma is lacking as is the situation in the present
report.
A more plausible explanation is that a neoplastic
“field effect” involving the peritoneum and ovarian
surface gives rise to multiple foci of synchronous
primary neoplasia. Supporting the latter theory for
the origin of serous surface papillary carcinoma is
the occurrence of malignant peritoneal serous
neoplasms following prophylactic oophorectomy in
women prone to ovarian cancer.10 These separate
carcinomas associated with serous surface papillary
carcinoma suggest that a “field effect” phenomenon
may extend beyond the peritoneum and ovary and
involve the omentum, mesentery, or retro-
peritoneum.
Long-term survival among patients with this
tumor have been rare. Chen et al. reported the
clinicopathologic features of 3 patients with diffuse
peritoneal involvement in which the patients,
treated with chemotherapy (Adriamycin®, cisplatin,
and Cytoxan®) had no evidence of disease five or
more years after initial diagnosis.1 2 3 4 5 6 7 8 White et al. re-
ported 11 patients with serous surface papillary
carcinoma of the ovary. The tumor was bilateral in
all but 1 patient, and all patients had omental peri-
toneal implants. All patients underwent total ab-
dominal hysterectomy and salpingo-oophorectomy
and were treated with chemotherapy (Adriamycin®,
cisplatin, and Cytoxan®). Eight patients died, 2 pa-
tients are alive with clinical evidence of recurrence,
and 1 patient is alive without evidence of disease at
44 months.11 Genedry et al.12 described 154 patients
with primary papillary peritoneal neoplasia followed
for a period from 2 to 40 years. Genedry felt the
disease is best understood as a primary peritoneal
tumor, possibly developing on the basis of irritating
agents reaching the abdominal cavity from the lower
genital canal, a process similar to one proposed for
the genesis of endometriosis. Genedry also stated
that the outcome without adjunctive therapy is ex-
cellent; thus, such therapy is contraindicated in
view of the death of only 2 of 154 patients with
disease. Dalrymple et al., in a comparison study of
31 patients with an initial diagnosis of extra-ovarian
serous papillary carcinoma, matched for stage and
grade of disease with a series of 139 patients with
primary epithelial ovarian carcinoma and managed
similarly, showed no difference in survival.13 The
median survival times were 11.3 months for patients
with extra-ovarian serous papillary carcinomas and
13.5 months for patients with equivalent primary
ovarian neoplasms.
Our patient had a serous papillary carcinoma,
probably derived from remnants of the pelvic
coelomic epithelium (canal of Nuck) that accom-
panies the round ligament in the inguinal canal,
and mimicked an inguinal hernia. Once a serous
papillary tumor was found, the likelihood of ovarian
metastases became pronounced; although this may
be the case in the majority of cases, it is well to be
aware that serous papillary tumors may arise de
novo from the pelvic peritoneum and not be in-
dicative of metastatic disease. ■
REFERENCES
1. Breen JL, Neubecker RD: Tumors of the round liga-
ment. Obstet Gynecol 19:771-780, 1962.
2. Foyle A, Al-Jabi M, McCaughey WTE: Papillary
peritoneal tumors in women. Am J Surg Pathol 5:241-249,
1981.
3. Swerdlow M: Mesothelioma of the pelvic peritoneum
resembling papillary cystadenocarcinoma of the ovary.
Am J Obstet Gynecol 77:197-200, 1959.
4. Kannerstein M, Churg J, McCaughey WTE, Hill DP:
Papillary tumors of the peritoneum in women:
Mesothelioma or papillary carcinoma. Am J Obstet
Gynecol 127:306-314, 1977.'
5. Holden J, Churg A: Immunohistochemical staining
for keratin and carcinoembryonic antigen in the diagnosis
of malignant mesothelioma. Am J Surg Pathol 8:277-279,
1984.
6. Ulbright TM, Morley DJ, Roth LW, Berkow RL:
Papillary serous carcinoma of the retroperitoneum. Am J
Clin Pathol 79:633-637, 1983.
7. Chen KTK, Flam MS: Peritoneal papillary serous
carcinoma with long-term survival. Cancer 58:1371-1373,
1986.
8. Gooneratne S, Sassone M, Blaustein A, Talerman A:
Serous surface papillary carcinoma of the ovary: A
clinicopathologic study of 16 cases. Int J Gynecol Pathol
1:258-269, 1982.
9. Mills SE, Andersen WA, Fechner RE, Austin MB:
Serous surface papillary carcinoma. A clinicopathologic
study of ten cases and comparison with stage III-IV ov-
arian serous carcinoma. Am J Surg Pathol 12:827-834,
1988.
10. Tobacman JK, Tucker MA, Kase R, et al.: Intra-
abdominal carcinomatosis after prophylactic oophorec-
tomy in ovarian cancer prone families. Lancet 2:759-767,
1982.
11. White PF, Merino MJ, Barwick KW: Serous surface
papillary carcinoma of the ovary: A clinical, pathologic,
ultrastructural, and immunohistochemical study of 11 !
cases. Pathol Ann 20:403-418, 1985.
12. Genedry R, Poliakoff S, Rotmensch J, et al.: Pri-
mary, papillary peritoneal neoplasia. Obstet Gynecol
5:730-734, 1981.
13. Dalrymple JC, Bannatyne P, et al.: Extraovarian
peritoneal serous papillary carcinoma. A clinicopathologic
study of 31 cases. Cancer 64:110-115, 1989.
650
NEW JERSEY MEDICINE
RADIOLOGY ROUNDS
Calcified Liver
Lesions
JAMES H. JACOBY, MD
FRANCIS X. O’BRIEN, MD
The authors present the differential diagnosis and the pathogenesis of
calcified liver lesions found on computed tomography scan.
A45-year-old Oriental female had a one-
month history of progressive generalized
pruritus. Aside from a prior history of ex-
posure to tuberculosis, she was in good health. The
patient smoked IV2 packs of cigarettes per day for
25 years. The patient noted her appetite had been
fair to poor, and her stools to be occasionally light
and her urine to be dark. Physical examination re-
vealed the patient to be clearly jaundiced. Rectal
examination was negative and stools were heme
negative.
Laboratory data revealed her urine to have 4 +
bilirubin. Her hepatitis profile was positive for prior
exposure to hepatitis B and hepatitis A viruses, but
there was no evidence of current infection. Serum
alkaline phosphatase was 1,830 (normal 37 to 158).
Her hemoglobin was 11.5 g/dL. Serum bilirubin was
3.35 mg/dL (normal .2 to 1.1 mg/dL) with a direct
bilirubin elevated at 2.59 mg/dL (normal 0 to .2 mg/
Dr. Jacoby, guest editor of this column, is acting chair-
man, Department of Diagnostic Radiology and Nuclear
Medicine, and Dr. O'Brien is assistant, Department of
Medicine, Cooper Hospital. Requests for reprints may be
addressed to Dr. Jacoby, Cooper Hospital/University
Medical Center, One Cooper Plaza, Camden, NJ 08103.
Figure 1. CT scan demonstrating a central calcified mass. Note
multiple hypodense areas within the liver (arrows).
dL). GGT was elevated at 441 units/L (top normal
45 units/L). SGOT was 130 units/L (top normal 40
international units/L). SGPT was 252 units/L (top
normal 50 international units/L). Her sedimentation
rate was 49 mm/hr (top normal 30 mm/hr).
Ultrasound evaluation of the patient’s right upper
quadrant revealed two echogenic masses in the right
lobe of the liver. Her common hepatic bile duct was
VOL. 87— NUMBER 8 AUGUST 1990
651
RADIOLOGY ROUNDS
normal with no evidence of dilatation or obstruction.
Subsequent computed tomography (CT) scan of her
abdomen is noted in Figures 1 and 2.
DISCUSSION
CT scan demonstrated a 4.7 cm calcified in-
trahepatic mass at the junction of the right and left
lobes of the liver (Figure 1). Central intrahepatic
biliary ductal dilatation is seen as hypodense
branching structures. Ultrasonography noted the
common hepatic bile duct is of normal caliber, in-
dicating therefore, that the level of this patient’s
biliary obstruction is above the level of the common
hepatic bile duct and is related to the demonstrated
calcification. A second smaller lesion measuring 1
cm is noted adjacent to the large intrahepatic
calcification (Figure 2).
Both benign and malignant lesions may calcify,
although this finding more commonly is seen with
malignancies. Benign hemangiomas present as dis-
crete homogeneous areas of diminished attenuation
and only uncommonly will calcify. Following bolus
intravenous contrast enhancement, these lesions are
said to characteristically demonstrate progressive
enhancement from the periphery until these lesions
become isodense. This characteristic finding is seen,
however, only in approximately 50 percent of the
cases. Magnetic resonance evaluation demonstrates
a characteristic very intense signal on heavily
weighted T2 images. The pattern of central calcifica-
tion noted in this patient is not characteristic of
hemangioma.
Hepatomas are known to calcify in approximately
10 percent of patients. Indeed, the incidence of
hepatomas in the Asian population is greater than
that in the United States population. In the Oriental
population, hepatocellular carcinoma frequently oc-
curs in association with cirrhosis. In contradistinc-
tion, in the United States population, these tumors
frequently arise de novo. Frequent presentation is
that of pain, weight loss, and palpable abdominal
mass with associated elevation of serum alphafeto-
protein. These tumors may be solitary or multiple,
encapsulated or diffuse. This diagnosis was a con-
sideration in this patient despite the lack of typical
presenting signs and symptoms.
Metastatic disease is the most common liver ma-
lignancy. Hepatic calcifications noted by CT have
been described in a variety of tumors including
metastasis from the colon, breast, kidney, ovary,
pancreas, stomach, melanoma, neuroblastoma,
Figure 2. CT scan demonstrating second small calcific focus
adjacent to the large calcified mass.
pleuromesothelioma, osteosarcoma, leiomyosar-
coma, carcinoid, cholangiocarcinoma, myeloma, and
lymphoma. Of these tumors, colorectal metastases
most commonly are associated with calcification;
however, this still is a relatively uncommon presen-
tation.
This patient subsequently had outpatient en-
doscopic retrograde cholangiopancreatography
(ERCP) that showed a normal caliber common bile
duct without filling of intrahepatic radicals. This
was followed by a CT guided-needle aspiration of the
liver mass, the cytology of which was positive for
malignant cells of the well-differentiated adenocar-
cinoma type consistent with gastrointestinal origin.
Biopsy at colonoscopy revealed a primary malig-
nancy.
The pathogenesis of calcification is felt to be
produced by the tumor itself or more commonly is
secondary to dystrophic calcifications related to
necrosis and hemorrhage within the mass. The pat-
tern of the calcification in metastases may be coarse
and conglomerate, as in this case, or fine and granu-
lar, punctate, or discrete and nodular. The pattern
and distribution of calcification, however, is variable
and nonspecific. It is interesting to note that
calcifications sometimes develop following radiation
therapy and/or chemotherapy. Pre-existing calci-
fications sometimes display a changing pattern of
increasing density following therapy. There appears
to be no prognostic significance to these findings,
however.
DIAGNOSIS
The diagnosis is calcified colon metastasis to the
liver causing intrahepatic biliary obstruction. ■
REFERENCES
1. Lee, JK, Sagel SS, Stanley RJ: Computed Body 2. Scatarige JC, Fishman EK, Saksouk FA, Siegelman
Tomography with MRI Correlation, 2nd Edition. New SS: Computed tomography of calcified liver masses.
York, NY, Raven Press, 1989. JCAT 7:83-89, 1983.
652
NEW JERSEY MEDICINE
CASE REPORT
Pneumothorax
Complication of Needle EMG of Thoracic Wall
JEFFREY MILLER, DO
Pneumothorax following needle electromyog-
raphy (EMG) has been reported in physical
rehabilitation literature but not in general
medical literature. The cases have involved the
supraspinatus,3 paracervical,1 serratus anterior mus-
cles,2 as well as nerve conduction at Erb’s point.4
This case involves a patient who developed a pneu-
mothorax following EMG nerve conduction studies
of the rhomboid muscles, the first reported case to
date.
A 56-year-old, thin white male had needle EMG
to evaluate a C5 neuropathy. The patient was a
heavy ethanol and cigarette abuser with
emphysema, who had undergone a left man-
dibulectomy and radical neck dissection, followed
by radiotherapy for head and neck cancer. The
procedure produced several neurologic complaints
including numbness of the left arm, shoulder, and
upper back, and resulted in the physical distortion
of the patient’s left face and neck. EMG studies were
performed to evaluate a C5 radiculopathy.
The left rhomboid major muscle was examined
and the study concluded without incident. Approx-
imately 40 minutes later, the patient became acutely
anxious, restless, and short of breath. Chest x-ray
revealed a large left pneumothorax with rightward
shift of the mediastinum. Tube thoracostomy im-
mediately relieved these symptoms.
Pneumothorax is an infrequent complication of
Dr. Miller is affiliated with UMDNJ. The manuscript was
submitted in December 1989 and accepted in March
1990. Address requests to Dr. Miller, 7000 Blvd. East,
47A, Guttenberg, NJ 07093.
needle EMG, but the medical community needs to
be aware of its occurrence. These cases can arise
when the muscle under study overlies the thorax,
neck, or axilla, and puncture of the pleural cavity
becomes possible. It is unlikely this patient could
have had a spontaneous pneumothorax following
rupture of a bleb due to his emphysema. The EMG
involved a muscle overlying the thorax; the pneu-
mothorax occurred on the side that had been nee-
dled, and the patient’s symptoms were temporally
related to the study. It is possible that this patient
was predisposed to pneumothorax as the result of his
prior radical head and neck surgery. The anatomic
distortions and consequent fibrosis following sur-
gery, possibly affecting the pleura, could have made
puncture of the pleura more likely.
This event is consistent with other reported cases.
In prior cases, the time during which pneumothorax
occurred ranged from immediately after the study
to three days later. In this instance, symptoms oc-
curred within 40 minutes. In prior cases, the pneu-
mothorax was typically small, ranging from 10 to 20
percent, and either was treated conservatively or by
tube thoracostomy. This case was more severe than
most in that it involved near total collapse of the
lung and produced tension in the pleural cavity that
compressed the mediastinal structures and necessi-
tated the use of a chest tube.
A literature search for similar cases revealed four
references.1'4 EMG of the thorax is not a benign
procedure and the risk of pneumothorax must be
weighed against its diagnostic benefits when select-
ing patients. ■
REFERENCES
1. Honet JE, Honet JC, Cascade P: Pneumothorax after
electromyographic electrode insertion in paracervical
muscles: Case report and radiologic analysis. Arch Phys
Med Rehabil 67:601-603, 1986.
2. Johnson EW, Parker WD: Electromyography exam-
ination, in Johnson EW (ed), Practical Electromyography.
Baltimore, MD, Williams & Wilkins, 1980, pp 1-16.
3. Rubenstein L, Twardzik FG, Mech KF Jr: Pneu-
mothorax: A complication of needle electromyography of
the supraspinatus muscle. Arch Phys Med Rehabil
68:561-562, 1987.
4. Peak JB, Roth JL, Schuchmann GF: Pneumothorax:
A complication of nerve conduction studies using needle
stimulation. Arch Phys Med Rehabil 63:187-188, 1982.
VOL. 87— NUMBER 8 AUGUST 1990
653
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654
NEW JERSEY MEDICINE
NOTEBOOK
■TRUSTEES’ MINUTES*
A regular meeting of the Board
of Trustees was held on June 10,
1990, at the executive offices in
Lawrenceville. Detailed minutes
are on file with the secretary of
each county society. A summary of
significant actions follows:
Report of the President . . .
(1) Hospital Medical Staff Sec-
tion Representative . . . Ap-
proved the appointment of Dr.
George T. Hare as the Hospital
Medical Staff Section representa-
tive.
(2) New Jersey State Medical
Underwriters, Inc., President
. . . Noted the search for a new
president is underway.
(3) Ad Hoc Committee on Un-
compensated Care . . . Noted Dr.
Costabile’s announcement of an ad
hoc committee to study the un-
compensated care issue, with Dr.
Louis L. Keeler as chairman and
Drs. John C. Baker, Charles J.
Moloney, Irving P. Ratner, and
Richard H. Sharrett as members.
(4) H.R. 4566 — Medicare Mal-
practice Dispute Resolution Act
of 1990 . . . Noted Dr. Costabile’s
suggestion that letters be written
to New Jersey’s congressional del-
egation supporting H.R. 4566.
Report of Executive Director . . .
(1) MSNJ Paid Membership . . .
Noted paid membership totaled
7,019 members as of May 31, 1990.
(2) Legislation . . . Noted the fol-
lowing bills: S-642 — Commissioner
of Health (permitting nonphysi-
cian to be commissioner of health):
MSNJ continues to oppose this
bill; S-1272 — Generic Substitu-
tion/Prescription Blank Change:
no movement on the bill; S-2051 —
Dispensing of Drugs by Physicians:
amended in committee; S-2607 —
Clear and Convincing Evidence in
Licensure Action (establishing
clear and convincing as the burden
of proof in a licensure action): out
of committee and favorable con-
sideration is expected in the Sen-
ate; and A-743 — Optometric Drug
Use: released from committee and
MSNJ continues to lobby against
the bill.
(3) Litigation . . . Noted the fol-
lowing: MSNJ versus Merin: hear-
ing date has been postponed until
early fall; State Board of Medical
Examiners versus Carrier Foun-
dation (action by SBME against a
physician in a disciplinary mat-
ter): the order issued by the Su-
perior Court of New Jersey de-
termined that the records obtained
from the Community Mental
Health Center through SBME’s
subpoena are to be stricken from
the disciplinary records, physi-
cian’s records are to be sealed, and
SBME is temporarily and per-
manently enjoined from obtaining
or utilizing any medical or psy-
chiatric records without the con-
sent of the physician; Medical
Waste Registration/Refunds: re-
funds must be paid by July 2, 1990,
and all physicians need to clarify
class of registration, and physi-
cians experiencing difficulty re-
garding DEP medical waste regu-
lation should contact MSNJ; Anti-
Smoking Coalition: MSNJ is on re-
cord as favoring anti-smoking
legislation but not in favor of sup-
porting a separate lobbying mech-
anism; SBME/Fee Complaint (in-
volving a physician who placed a
delinquent fee matter into liti-
gation): and MSNJ is observing
the case carefully; SBME versus
Sinha: decision still is pending;
MSNJ versus State Board of
Physical Therapy: court has not
rendered a decision; and PRO ver-
sus MSNJ: rulings state:
As a matter of law, there is no reason
why a physician’s response to PRO of
New Jersey, Inc. must be done per-
sonally in order for PRO to consider it.
Likewise, there is no reason why a
response made by counsel who has
been retained to represent the physi-
cian during the peer review process is
not binding on the physician.
PRO of New Jersey, Inc. is entitled to
communicate directly with physicians
to initially notify them that a potential
quality problem exists, in furtherance
of PRO’s contractual and statutory ob-
ligations.
The motion of PRO of New Jersey, Inc.
for a protective order prohibiting the
defendants from deposing Mr. Madden
and Mr. Margolies will be denied.
UMDNJ Report . . . Noted the
following items from Dr. Bergen’s
monthly report: appreciation for
MSNJ’s support of increased fund-
ing for nursing and allied health
education in academic institutions
and hospital settings; joint nursing
program with Middlesex County
College and UMDNJ; photo-
graphic display at UMDNJ-Smith
Library of Newark City Hospital/
Martland Medical Center; and Dr.
Peter Lobel, assistant professor of
pharmacology, is the 1990 Searle
Scholar.
NJ Hospital Association . . .
Noted the following items from
Mr. Scibetta’s monthly report: de-
nial of the across-the-board adjust-
ment to the labor proxy of hospital
VOL. 87— NUMBER 8 AUGUST 1990
655
rates; the first meeting of the Gov-
ernor’s Commission on Health
Care Costs suggested major reform
is necessary in the areas of af-
fordability of health care in-
surance, changing the hospital re-
imbursement system to further
contain costs; and more coordi-
nation of the planning and financ-
ing of health care services.
Committee on Annual Meeting
. . . Approved the daily schedule
for the 1991 Annual Meeting and
the following:
That the 225th Annual Meeting of
MSN.J be at the Trump Taj Mahal
Casino Resort in Atlantic City, from
Saturday, April 27 through Wednes-
day, May 1, 1991.
Council on Medical Services . . .
Approved the following:
That MSN-J conduct a data-gathering
survey on the issue of abuses hy in-
surance companies (delay of payment,
harassment, etc.).
Also approved the following rec-
ommendations:
That MSNJ recognize that Penn-
sylvania Blue Shield is inappropriately
denying or postponing payments for
prostatectomy in cases of carcinoma of
the prostate where precertification is
not required.
That MSNJ request Pennsylvania
Blue Shield to amend its payment
procedures so that delays and/or de-
nials in payment for prostatectomy in
cases of carcinoma of the prostate are
eliminated.
That MSNJ request Pennsylvania
Blue Shield to review its payment
procedures in all cases where precerti-
fication numbers are not required, as
well as other such procedures having
no number due to emergency circum-
stances.
Task Force on Patient Care for
the Under-Insured . . , Voted to
refer the following recommen-
dation back to the Task Force for
further consideration and to the
Hospital Medical Staff Section for
their input:
That the mechanism of payment for
services under the Uncompensated
Care Trust Fund be administered via
a hospital-created intermediary con-
cept.
New Business . . .
(1) Walkathon To Benefit
Women and Children with AIDS
. . . Noted that the opinion of the
Board was that the program should
be supported on an individual
basis, not for MSNJ to be a cor-
porate sponsor.
(2) Medicare Physician Regu-
lation Relief Amendments of 1990
. . . Referred the Medicare-related
issues to the AMA Delegation as
these issues will be considered at
the upcoming AMA Annual Meet-
ing.
(3) Proposal for Improving U.S.
Health Care System . . . Referred
to the AMA delegation for con-
sideration the proposal and resolu-
tion from the Medical Society of
the State of New York calling for
improvements to the U.S. health
care system.
(4) A-3531 — Prescription Privi-
leges for Nurse/Midwives . . .
Voted to oppose this bill that
would grant prescriptive authority
for nurse/midwives under their
standing orders within their
protocols.
Correspondence . . . Received
correspondence from the following:
Frances J. Dunston, MD, MPH,
State Commissioner of Health, in
response to MSNJ’s concerns
about the need to provide due
process in the quality assurance
plans of New Jersey’s UROs; re-
view organizations; Congressman
H. James Saxton in response to
MSNJ concerning H.R. 3102, Pub-
lic Health Response to AIDS Act of
1989, and stating he will keep
MSNJ’s views in mind when the
bill reaches the House floor; and
Congressman Chris Smith in
response to MSNJ’s concerns re-
garding Medicare regulations. □
A meeting of the Board of
Trustees was held on May 5, 1990,
at the Sands Hotel, Casino and
Country Club, Atlantic City. De-
tailed minutes are on file with the
secretary of your county society. A
summary of significant actions fol-
lows:
In Memoriam . . . Observed a mo-
ment of silence and received a
memorial resolution for Peter
Sweetland, president of the Medi-
cal Inter-Insurance Exchange of
New Jersey.
Report of the President . . .
(1) Optometric Drug Use
(A-743) . . . Noted a letter from
Philip J. Cocuzza, executive direc-
tor of the Dental Association, in-
dicating the Dental Association’s
support of a “no position” stance
on this bill.
(2) Strategic Planning
Proposals . . . Referred MSNJ’s
long-range goals and objectives to
Doctor Costabile for referral to the
appropriate councils and commit-
tees.
Report of Executive Director . . .
(1) MSNJ Paid Memberships
. . . Noted MSNJ paid member-
ship totaled 6,809 as of March 31,
1990.
(2) Financial Statements . . .
Reviewed and approved the
financial statements for the period
ending March 31, 1990.
(3) Legislation . , . Noted the fol-
lowing: S-642 (Deletion of MD Re-
quirement for Commissioner of
Health) passed the Senate with a
vote of 28-7; A-3359 (Requirement
that All Schedule II Prescriptions
Be in Triplicate), would require
the Department of Health to
provide every doctor with prescrip-
tion pads to be used for schedule
II drugs; S-2607 (Requirement that
Burden of Proof in a Licensure Ac-
tion Be “Clear and Convincing”
Evidence), will be actively sup-
ported by MSNJ and now is out of
committee.
Litigation . . . Noted the follow-
ing: MSNJ versus Merin
(Surcharge), scheduled for argu-
656
NEW JERSEY MEDICINE
ment on June 4, 1990; PRO versus
MSNJ, the judge has reserved de-
cision; MSNJ versus State Board
of Physical Therapy, pending in
State Supreme Court; SBME ver-
sus Sinha, pending a decision by
the Appellate Division; and No-
Fault, awaiting action by MSNJ
until decision by the federal court
is announced.
Council on Legislation. . . Ap-
proved all the positions rec-
ommended by the Council with the
exception of the following: S-1272
(Generic Substitution/Prescription
Blank Change), voted to change
the position to “No Action”
provided the bill is amended to use
the phrase brand necessary; S-2051
(Dispensing of Drugs by Physi-
cians), voted to change the posi-
tion to “No Action” and to seek
certain amendments and clari-
fication; S-613 (AIDS), voted to
change the position to “Disap-
proved;” and A-3042 (Medicare
Assignment), voted unanimously
to change the position to “Active
Opposition.”
Council on Medical Services. . .
Approved the following:
That the Council on Medical Services
be authorized to test a disability form
devised by Doctor William E. Ryan,
and report back to the Board of
Trustees.
That the Board of Trustees advise the
membership of its obligation to
provide information to insurance com-
panies with the written consent of the
patient, and of its right to charge a
reasonable fee for this service.
Task Force on the Shortage of
Nurses and Technical Personnel
. . . Approved the following rec-
ommendations after deletion of the
words in italics:
That MSNJ urge the Governor to sup-
port increased funding in his budget
for nursing and allied health education
in academic institutions and hospital
settings — specifically for programs in
the following fields: dietetic in-
ternship; EMT — paramedic: surgical
technology; radiography; ultra-
sonography; nurse midwifery; nuclear
medicine; respiratory therapist; respir-
atory technician; dental assisting; den-
tal hygiene; physical therapy; nursing
(Master’s)-, medical technology; toxi-
cology; and cytotechnology.
That the New Jersey Hospital Associa-
tion, the New Jersey State Nurses As-
sociation, and the appropriate rep-
resentatives in the fields of study men-
tioned also be urged to contact the gov-
ernor regarding funding for nursing
and allied health education programs.
Unfinished Business . . .
(1) Annual Grant to the
Academy of Medicine of New
Jersey . . . Voted to address this
issue in executive session.
(2) H.R. 3102 (Public Health
Response to AIDS Act of 1989)
. . . Received thank you letter from
Congressman Dannemeyer for
MSNJ’s endorsement of this bill.
(3) Jury Trial — Driving While
Intoxicated . . . Noted that the
Supreme Court decided that all ve-
hicular violations other than death
by automobile are to be tried in
municipal courts without juries.
New Business. . .
(1) Department of Health Regu-
lation on Endoscopic Procedures
. . . Authorized Mr. Maressa to
discuss a proposed regulation (re-
quiring an anesthesiologist to be
present during endoscopic
procedures when conscious in-
travenous sedation is used outside
the operating room) with the ap-
propriate individual at the Depart-
ment of Health.
(2) Physician Assistants . . .
Noted Dr. Hirsch reiterated
MSNJ’s continuing opposition to
the recognition of physician assis-
tants and that MSNJ expects to
take part in the debate about the
physician assistants pilot program.
A reorganization meeting of the
Board of Trustees was held on May
9, 1990, at the Sands Hotel, Casino
and Country Club, Atlantic City.
Detailed minutes are on file with
the secretary of your county so-
ciety. A summary of significant ac-
tions follows:
Reorganization Meeting . . .
Welcomed the following new mem-
bers: Joseph A. Riggs, MD, presi-
dent-elect; William E. Ryan, MD,
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
VOL. 87— NUMBER 8 AUGUST 1990
657
first vice-president; and Joseph N.
Micale, MD, second vice-presi-
dent.
Referrals from the 1990 House of
Delegates . . . Noted all the ac-
tions for the referrals from the 1990
House of Delegates are explained
in the Transactions section of
NEW JERSEY MEDICINE
(August 1990, pages 674-Tr 81);
this refers to Resolutions #1, #2, #3,
#4, #5, #6, #9, #11, #12, #14, #15,
#16, #17, #18, #19, #21, #23E, #24E,
#26E, #27E, Annual Report of the
Council on Mental Health, and
Gender Exploitation in the Work-
place.
Unfinished Business. . .
(1) Foundation of UMDNJ. . .
Agreed to supply MSNJ member-
ship mailing labels to the Foun-
dation of UMDNJ for their use in
soliciting funds.
(2) Annual Meeting Site
Proposal . . . Was advised that
proposals from Trump Taj Mahal
Casino Resort and other hotels will
be taken into consideration by the
Committee on Annual Meeting in
recommending a site for the 1991
MSNJ Annual Meeting.
HHUMDNJ NOTES HH
Surgeons at UMDNJ are repair-
ing severely fractured legs without
putting patients in traction, saving
them up to 12 weeks of recovery
time. Orthopedic surgeons at
UMDNJ-Robert Wood Johnson
Medical School, Camden, among a
few in New Jersey who specialize
in this procedure, are using a de-
vice called an interlocking femoral
nail to fix the fractures internally.
The device is a rod about one-half
inch in diameter with two trans-
fixing screws, one at the top and
one on the bottom. To repair the
fracture, the rod is installed inside
the femur and then a transfixing
screw is placed at each end to lock
the rod in place. With this support,
patients can begin putting weight
on the leg the day after surgery.
Without the device, a patient
would spend 6 to 12 weeks in trac-
tion. Following physical therapy,
the patient’s total recovery time is
about 3 months. In most cases, the
rod is removed a year to 18 months
following the operation.
The Lyme Disease Center at
UMDNJ-Robert Wood Johnson
Medical School is accepting pa-
tients for two studies to evaluate
the relative efficacy of current drug
treatment. The Center also has es-
tablished a tollfree information
hotline to answer questions about
the disease, an increasing problem
especially in the northeastern
United States. The hotline number
is 1-800-245-LYME and is avail-
able Monday through Friday from
noon to 8 P.M. The Lyme Disease
Center also conducts research to
uncover the basic mechanism be-
hind the disease and the reasons
some tick victims become sick and
recover, some do not get sick, and
others get sick and do not recover.
Callers to the Center’s hotline can
receive written information about
the disease and referral to the
Center if necessary.
Camden County dedicated a fa-
cility at its Lakeland complex in
Gloucester Township to house a
UMDNJ addiction-treatment and
research program. Freeholder Di-
rector Robert E. Andrews, Free-
holder Joseph F. Carroll, liaison for
buildings and operations, and
Freeholder Michael J. DiPiero,
chairman of the department of
health and human services, dedi-
cated the facility. Dr. Martin
Iguchi, assistant professor of psy-
chiatry at the Center for Addiction
Research, an arm of LJMDNJ-
School of Osteopathic Medicine, is
project director. Dr. Jerome Platt
is director of the Center. □ Stanley
S. Bergen, Jr, MD
■■NEW MEMBERS**
The Medical Society of New Jersey
would like to welcome the follow-
ing new members to our County
and State societies:
Atlantic County
Isaac S. Mordecai, MD
Nadia Sadik, MD
Bergen County
Jose H. Duque, MD
Alberto M. Goldwaser, MD
Richard M. Grose, MD
Patricia L. Hughes, MD
Judith P. Lustig, MD
Scott B. Pomerantz, MD
Peter I. Praeger, MD
John R. Scheuch, MD
Anthony P. Volpe, MD
Sharad D. Wagle, MD
Darryl S. Weiss, MD
Burlington County
David G. Ansel, MD
Carl G. Conrad, MD
Andres T. Guevarra, MD
Dhiraj K. Panda, MD
Michael A. Wappel, MD
Camden County
Leonid Belopolsky, MD
William E. Benson, MD
Patricia M. Browne, MD
Carman A. Ciervo, DO
Neil M. Cohen, MD
Manuel R. De La Cruz, MD
Dean A. Drezner, MD
Guillermo C. Elkouss, MD
Jack Goldberg, MD
Terry A. Gubitosi, MD
Alexis Harvey, MD
Steven D. Herman, MD
Diane M. McClain, DO
Paresha S. Shah, MD
Peter G. Sperandio, MD
Coleen C. Whitman, MD
Essex County
Mark D. Chase, MD
Peirre R. Leger, MD
Janice L. Puttorak, MD
Gloucester County
Steven J. Glass, MD
William A. Ollar, DO
Hunterdon County
Cheryl A. Kennedy, MD
Stanley A. Sheft, MD
Mercer County
Robyn F. Agri, MD
John Caruso, Jr, MD
Ahmad Farzad, MD
Kathleen Gelperin, MD
658
NEW JERSEY MEDICINE
Jose M. Gonzalez-Acuna, MD
Raj N. Lalla, MD
James B. Loftus, MD
Angela Merlo, MD
Scott D. Miller, MD
Jonathan R. Sachs, MD
Gary A. Smotrich, MD
Cindy P. Sussman, MD
Michael H. Yamane, MD
Middlesex County
Emelita A. Ayos, MD
Rena M. Nora, MD
Robert I. Park, MD
Frank A. Simon, MD
Heidi K. Winchman, MD
Monmouth County
Richard I. Sultan, DO
Morris County
Peter E. Bippart, MD
Michael R. Dara, MD
Elmer S. Gilo, MD
Darlene J. Goldstein, MD
Michael M. Mainero, MD
Donald H. Marks, MD
Mark W. Moritz, MD
Jeffrey C. Parker, MD
Jeanne R. Schwartz, MD
Mark S. Silidker, MD
John G. Soriano, MD
Ocean County
Frank C. Alario, MD
Richard J. Borgatti, MD
John Drulle, MD
Emilia C. Eiras, MD
Joseph J. Guarino, Jr, MD
Russell L. Harrell, MD
Sang K. Kim, MD
Rangaswamy S. Lokchander, MD
Stewart F. Miller, MD
Donato J. Santangelo, III, MD
Victor C. Tauro, MD
Iraj K. Varzi, MD
Jean C. Wang, MD
Henry K. Yu, MD
Passaic County
Elizabeth A. Boyle, DO
Michael K. Buckley, MD
Shlomo Charlap, MD
Michael A. D’Anton, III, MD
Alfred M. DiRenzo, DO
Justin F. Fernando, MD
Michael J. Flintrop, MD
Robert M. Gajdos, MD
Jonathan A. Gold, MD
Alan J. Heideman, MD
Lawrence Kraut, MD
Michael J. Martino, MD
Alexander Mittelmann, MD
Michael J. Pereira, MD
David M. Samuel, MD
Sheldon H. Teperman, MD
Somerset County
Anthony Frisoli, MD
Fikry W. Isaac, MD
Cheryl J. Rubin, MD
Sussex County
Brian F. Newman, MD
Donald J. Rubino, MD
Union County
Roger W. Countee, MD
Steven L. Gerber, MD
Christopher J. Minas, MD
Barry J. Pollack, MD
Israel F. Rebarber, MD
Amir Salomon, MD
■■PLACEMENT FILEHH
The following physicians have
written to the MSNJ executive of-
fices seeking information on pos-
sible opportunities for practice in
New Jersey. The information listed
below has been supplied by the
physicians. If you are interested in
any further information, we sug-
gest you make inquiries directly to
the physicians.
INTERNAL MEDICINE
Marc Kesselhaut, MD, 1 Rustic Ridge,
C16, Little Falls, NJ 07424. St.
George’s University 1986. Board eli-
gible. Solo or partnership in Mercer,
Somerset, Burlington, Hunterdon, or
Middlesex counties. Available Sep-
tember 1990.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner-
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital-based.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Wood-
side Ave., Trenton, NJ 08618. Rutgers
1980. Board certified. Part time or full
time. Available.
SPECIAL ISSUE
Lyme Disease In New Jersey
Additional copies will be available for $6.50
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
VOL. 87— NUMBER 8 AUGUST 1990
659
PHILADELPHIA HEART INSTITUTE
Presbyterian Medical Center
39th and Market Streets
Philadelphia, PA 19104-
ii
FIRST ANNUAL SYMPOSIUM
. 1!
Cardiovascular Disease
State-Of-The-Art 1990
12-13 October 1990
The Rittenhouse Hotel
Philadelphia, Pennsylvania
This two-day symposium is designed to give the physician with a busy clinical
practice the opportunity to review the field with experts renowned for their
contributions to the field. Presentations will focus on the most recent advances in
the medical, non-surgical and surgical management of coronary and valvular heart
diseases and in the use of state-of-the-art diagnostic procedures.
Course Director, Ami E. Iskandrian, M.D.
Highlights of the Symposium include:
V The Unstable Plaque: Medical Therapy and PTCA
V Expanding Application of Nuclear Cardiology
V New Techniques of Non-Surgical Revascularization
V Left Ventricular Remodelling after Acute Myocardial Infarction
V Optimal Use of Quantitative Doppler Echocardiography
V The Risk-Benefit Dilemma of Antiarrhythmic Therapy
Co-Sponsored by
■ 44 CME Credits The Southeastern Pennsylvania
■ Reservations Limited to 200 Affiliate of
■ Contact: Ms. Deborah Wal (215) 662-9084 The American Heart Association
660
NEW JERSEY MEDICINE
ALLERGY
October
19 General Allergy
1- 2 P.M. — North Princeton
Developmental Center, Princeton
(AMNJ)
25- In Vitro Allergy Seminar
28 Myrtle Beach,
Martinique
( Holy Name Hospital)
ANESTHESIOLOGY
September
18 Meeting
6-9 P.M. — Ramada Inn,
Clark
(New Jersey State Society
of Anesthesiologists)
22 Tenth Annual Clinical
Anesthesia
8 A.M.-4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
CARDIOLOGY
September
19 Indications for Invasive Studies
10:30-1 1:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
DERMATOLOGY
October
10 Common Tumors of the Skin
10:30-11:30 A. M— St. Mary’s
Hospital, Passaic
(AMNJ)
INFECTIOUS DISEASE
September
5 AIDS Training and Resource
Program for Hospital Health
Educators
2- 3 P.M. — John E. Runnells
Hospital, Berkeley Heights
(AMNJ and NJDOH)
11 Counseling and Testing for HIV
Infection
11:30 A.M.-l P.M. — UMDNJ-
University Hospital, Newark
(AMNJ and NJDOH)
14 AIDS Training and Resource
Program for Hospital Health
Educators
9:30-11:30 A.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ and NJDOH)
17 Counseling and Testing for HIV
Infection
10-11 A.M. — Hackensack Medical
Center, Hackensack
(AMNJ and NJDOH)
20 Using Counseling and Testing
as a Management Strategy for
the HIV-Infected Individual
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
24 Clinical Management of HIV
Infection
10-11 A.M. — Hackensack Medical
Center, Hackensack
(AMNJ and NJDOH)
26 AIDS Training and Resource
Program for Hospital Health
Educators
9-10 A.M. — Hackensack Medical
Center, Hackensack
(AMNJ and NJDOH)
27 AIDS Training and Resource
Program for Hospital Health
Educators
9:15-10:15 A.M. — Saint Michael’s
Medical Center, Newark
(AMNJ and NJDOH)
October
4 Counseling and Testing for HIV
Infection
11:45 A.M.-l P.M. —John F.
Kennedy Medical Center, Edison
(AMNJ and NJDOH)
10 Using Counseling and Testing
as a Management Strategy for
the HIV-Infected Individual
9:30-10:30 A.M. —Bergen Pines
County Hospital, Paramus
(AMNJ and NJDOH)
11 Using Counseling and Testing
as a Management Strategy for
the HIV-Infected Individual
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
11 Clinical Management of HIV
Infection
11:45 A.M.-l P.M. —John F.
Kennedy Medical Center, Edison
(AMNJ and NJDOH)
17 Diagnosis and Treatment of
HIV Infection
8- 9 A.M. — Barnert Hospital,
Paterson
(AMNJ and NJDOH)
17 Clinical Management of HIV
Infection
9- 10 A.M. — Raritan Valley
Community College
(AMNJ and NJDOH)
MEDICINE
September
4 Grand Rounds
11 8:30-10 A.M. — Elizabeth General
18 Medical Center, Elizabeth
25 (Elizabeth General
Medical Center)
5 Proper Use of Antibiotics
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
7 Modern Surgical Treatment of
Peptic Ulcer Disease
7:30-8:30 A.M. — Freehold Area
Hospital, Freehold
(AMNJ)
9 Developments in Emergency
Care
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
10 Hepatitis
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
1 1 Topics in Public Health
25 12:15-1:30 P.M.— John Fitch
Plaza, Trenton
(AMNJ)
12 Living Wills
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
12 New Practice Program
8 A.M. -3:30 P.M.— MSNJ, Two
Princess Road, Lawrenceville
(MIIENJ)
VOL. 87— NUMBER 8 AUGUST 1990
661
r
v.
The Johns Hopkins University School of Medicine
Department of Emergency Medicine
presents
Third Annual
Written Boards in emergency Medicine:
B Comprehensive Review
October 27 - November 2, 1990
Baltimore, Maryland
This seven day program is designed to provide a comprehensive review of the fund of
knowledge necessary to enable successful completion of the certification examinations
offered by the American Board of Emergency Medicine (ABEM). The official complete schedule
of examination dates is available from the ABEM. Candidates for whom this course may be most
helpful are those scheduled for: written recertification examination on November 4, 1990, written initial certifying
examination on November 5, 1990, or the oral initial certifying examination on January 27-30, 1991. This course
is recommended for both the established physician-in-practice and the physician who has recently completed residency
training. It is anticipated that course participants will be near completion of a self-directed plan of study. Some written
board candidates have chosen to begin their plan of study a year in advance by taking this course, others appreciate
a structured and systematic review just days prior to the written certifying exam.
Our curriculum is designed based primarily on the core content in Emergency Medicine which was developed
jointly by the American Board of Emergency Medicine and the American College of Emergency Physicians. Alloca-
tion of lecture time for specific areas has been determined by the relative weight of content areas as delineated
by the ABEM for examination purposes. The program objectives are to enable registrants to: review and reinforce
the organization and comprehension of the essentials of the core curriculum in Emergency Medicine, refine
test taking skills, gain the psychological edge to be at your peak performance on the examination day, and enhance
your clinical skills for improved patient care.
The response to our course offering in the past has been most gratifying. We have listened to the feedback pro-
vided by prior registrants and course faculty, and this led to several new features. This year we will include a formal
didactic session on preparation for the oral exam. Additionally, elective opportunity for private oral board
preparatory tutorials and small group oral board simulation will be available during the program. The underlying
philosophy of our program is unchanged and our primary focus will remain the written board exam candidate. There
are many resources from which to learn the information suggested by the core content curriculum. Among them
are Rosen's Textbook of Emergency Medicine, the ATLS/ ACLS manuals and numerous other texts, monographs and
journals. This year we have chosen to present the core content information in a format that correlates organiza-
tionally with the text. Emergency Medicine: A Comprehensive Study Guide - American College of Emergency
Physicians, edited by Tintinalli, Krome and Ruiz, f inally, we have added a three component special session which
will provide practical suggestions and strategies on how to achieve optimal performance on your examina-
tion day.
A variety of instructional formats are utilized which will allow each registrant to gain the most from this program.
Formal lectures, a comprehensive 'syllabook' (which is mailed to you in advance), a total of over 1 000 single answer
multiple choice "pretests questions" for self assessment purposes administered prior to each half day lecture
session, self teaching laboratory which is open 1 4 hours daily, faculty panel question/answer discussions follow-
ing each half day session, x-ray view box displays, PEER IV review sessions, and elective oral board practice/
tutorial sessions will be available for enhancement of your preparation.
The teaching faculty consists exclusively of emergency medicine physicians who have taken the written board
and are noted for their interest and expertise in teaching. We are fortunate to have retained almost all of the best
received 1989 faculty and several outstanding additional faculty members from community practices, academic
institutions throughout the country and the Johns Hopkins Medical Institutions.
Registration will be limited. Plan now to join us in the fall.
GUEST FACULTY
James L. Baker, MD, MPH, FACEP
Edward Balgiano, MD, FACEP
Robert A. Barish. MD, FACEP
Georges C. Benjamin, MD FACEP, FACP
Edmund Bolton, MD, FACEP
Brian Browne, MD, FACEP
Dominick Catalano, MD, FACEP
Richard Edlich, MD, PhD
Randy S. Ellis, MD, FACEP
Beverly Fauman, MD, FACEP
Charles A. Garfield, PhD.
Keith T. Ghezzi MD
Georgina Groleau, MD FACEP
Edith L. liambrick, MD FACEP
Martin C. Flellman, MD FACEP FAAP
Robert Hoffman, MD
Ronald L. Krome, MD
Robert L. Levine, MD
Jonathan Olshaker, MD, FACEP
Joseph Ornato, MD, FACC
Thomas Pellegrino, MD
Carol S. Rivers, MD, FACEP
Daniel T. Schelble, MD FACEP
Mark Smith, MD, FACEP
J, Stephan Stapczynski MD, FACEP
Louise Andrew, MD, FACEP
Timothy Buchman, MD PhD
Julie Casani, MD, MPH, FACEP
William Fabbri, MD FACEP
JOHNS HOPKINS FACULTY
Gabor Kelen, MD FRCP(C), FACEP
Horace K. Liang, MA, MD, FACEP
Christopher Morrow MD, FACEP
Kathryn A. Reihard, MD
J. Andrew Sumner, MD, FACEP
John Wogan. MD, FACEP
Thomas Kirsch, MD, MPH
Keith T. Sivertson, MD, FACEP Carol Jack Scott, MD, MSEd, FACEP
Director, Department of Program Director
Emergency Medicine
For Further Program Information: Office of Continuing Education, The Johns Hopkins Medical Institutions
Turner 20, 720 Rutland Avenue, Baltimore, Maryland 21205-2195, (301) 955-2959
662
NEW JERSEY MEDICINE
27 Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
8- 9 P.M. — Freehold Area,
Hospital,
Freehold
(AMNJ)
October
2 Grand Rounds
9 8:30-10 A. M. — Elizabeth General
16 Medical Center, Elizabeth
23 (Elizabeth General
30 Medical Center)
3 Aminoglycosides
9- 10 A. M. — Warren Hospital,
Phillipsburg
(AMNJ)
3 Prevention of Lower Extremity
Amputations
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
3 Diagnosis and Treatment of
Neuroleptic Malignant
Syndrome
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
9 Prevention of LowTer Extremity
Amputations
8-9 A.M. — Barnert Hospital,
Paterson
(AMNJ)
9 Topics in Public Health
23 12:15-1:30 P.M. —John Fitch
Plaza, Trenton
(AMNJ and NJDOH)
11 Diabetic Nephropathy
1:30-2:30 P.M. — Vineland
Developmental Center, Vineland
(AMNJ)
13 Late Effects of Polio
8 A.M. -3:30 P.M. — Somerset
Marriott Hotel, Somerville
(Raritan Valley Post Polio
Support Group)
14 Diabetic Nephropathy
1:30-2:30 P.M. — Roosevelt
Hospital, Metuchen
(AMNJ)
15 Meeting
6:30 P.M. — The Manor, West
Orange
(Neurological Association of New
Jersey/Neurology Section, AMNJ)
16 Citrate and Nephrolithiasis
Overlook Hospital, Summit
(Nephrology Society of
New Jersey)
17 Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
1 7 Prevention of Lower Extremity
Amputations
1- 2 P.M. — V.A. Medical Center,
Lyons
(AMNJ)
20 New Practice Program
8 A.M. -3:30 P.M. —Medical
Society of New Jersey,
Lawrenceville
(MIIENJ)
OBSTETRICS/GYNECOLOGY
September
10 Diabetes in Pregnancy
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ)
12 Diabetes in Pregnancy
2- 3 P.M. — Welkind Rehabilitation
Hospital, Chester
(AMNJ)
October
2 Diabetes in Pregnancy
8-10 A.M. — Barnert Hospital,
Paterson
(AMNJ)
16 Diabetes in Pregnancy
8- 9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
18 Neonatal Problems
7:30-8:30 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
20 Hypertensive Disease in
Pregnancy
9 A.M. -4:30 P.M. — Saddle Brook
Marriott, Saddle Brook
(Seton Hall University Graduate
School of Medical Educa tion)
ONCOLOGY
September
13 Tumor Board Case Presentation
9- 10 A.M. — Irvington General
Hospital, Irvington
(Irvington General Hospital)
ORTHOPEDICS
October
26- 15th Annual New Jersey
27 Orthopaedic Symposium in
Conjunction with the 23rd
Annual Northeastern Mid-
Atlantic Orthopaedic Residents’
Conference
3:15 P.M. — Hyatt Regency Hotel,
New Brunswick
(AMNJ and NJ Orthopaedic
Society)
PSYCHIATRY
September
4 Psychiatry Grand Rounds
11 8:30-10 A.M. — Elizabeth General
18 Medical Center, Elizabeth
25 (Elizabeth General
Medical Center)
5 Mitral Valve Prolapse in Eating
and Panic Disorders
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
6 Computerized EEGs — Role in
Clinic Psychiatry
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
13 HIV Spectrum Disorder:
Counseling, Psychotherapy, and
Pharmacotherapy
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
20 Premenstrual Syndrome:
Diagnosis and Treatment
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
26 Velvet and Armour
All day — Carrier Foundation,
Belle Mead
( Carrier Foundation)
26 Obsessive Compulsive Disorder
12 Noon-1 P.M. — Trenton
Psychiatric Hospital, Trenton
(Trenton Psychiatric Hospital)
October
2 Psychiatry Grand Rounds
9 8:30-10 A.M. — Elizabeth General
16 Medical Center, Elizabeth
23 (Elizabeth General
30 Medical Center)
4 Biological Origins of Alcoholism
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
5 Annual Fall Meeting
6:30 P.M. — Hyatt Regency,
New Brunswick
(NJ Psychiatric Association)
25 Early Office Recognition of
Depression Relating to Patient
Management
12 Noon — 1 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
RADIOLOGY
September
13 Radiology Meeting
7:30-9:30 P.M. — Saint Barnabas
Medical Center, Livingston
(Radiological Society of NJ)
October
20 MRI Seminar
8 A.M. -5 P.M. — Hyatt Regency,
New Brunswick
(Radiological Society of NJ)
VOL. 87— NUMBER 8 AUGUST 1990
663
mi iiiii i
A
PHILADELPHIA HEART INSTITUT
of Presbyterian Medical Center
I Cardiology
Update v
designed for the physician and provides an intensive
survey of the current status of clinical cardiology. . .
1990-91
Moderators
Leonard N. Horowitz, M.D.
Ami E. Iskandrian, M.D.
Bernard L. Segal, M.D.
William J. Untereker, M.D.
5 September
3 October
- Bedside Diagnosis of the Cardiac Patient (with stethophones)
- The Electrocardiogram (ECG slides discussed)
7 November - Recent Advances in the Treatement of Acute Mycardial Infarction
5 December - Angina Pectoris
9 January - Stroke: Diagnosis and Management in the 1990's
6 February - Hypertension: 1990's
6 March - Women and Heart Disease
3 April - The Sudden Death Crisis in America
1 May - Geriatric Cardiology
Wednesdays, 3:00 - 5:00 p.m.
Case Presentations
Reception Following Session
CME Credits
No Registration Fee
Reservations: (215) 662-8627
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
664
NEW JERSEY MEDICINE
MSNJ ANNUAL MEETING
The 1990-1991 MSNJ Board of Trustees
(seated, left to right): Bernard Robins, MD; Gerald H. Rozan, MD; Leticia V. DeCastro, MD; Joseph N. Micale, MD; Paul J.
Hirsch, MO; Douglas M. Costabile, MD; Joseph A. Riggs, MD; William E. Ryan, MD; (standing, left to right): Carl Restivo, Jr,
MD; John J. Pastore, MD; G. Gerson Grodberg, MD; Edwin W. Messey, MD; Fred M. Palace, MD; Philip J. Jasper, MD; Shah
M. Chaudhry, MD; Joel S. Cherashore, MD; Angelo S. Agro, MD; George T. Hare, MD; and George J. Neumaier, MD. Missing:
Anthony P. Caggiano, Jr, MD; Michael M. Heeg, MD; Louis L. Keeler, MD; R. Gregory Sachs, MD; and Robert Schnitzlein.
VOL. 87— NUMBER 8 AUGUST 1990
667
MSNJ ANNUAL MEETING
Karen Morrone, Sandoz pharmaceutical representative, presents the 1990 Na-
tional Medical Journalism Special Award to NEW JERSEY MEDICINE Editor-in-
Chief, Howard D. Slobodien, MD.
James Davis, MD, past-president of the American Medical Association, ad-
dresses the MSNJ House of Delegates.
Anthony P. Caggiano, Jr, MD, a new member
of the MSNJ Board of Trustees, attends the
House of Delegates.
Leticia V. DeCastro, MD, a new member of the
MSNJ Board of Trustees, prepares for the
House of Delegates meeting.
668
NEW JERSEY MEDICINE
Paul J. Hirsch, MD (right), presents the presidential plaque and
certificate to incoming president Douglas M. Costabile, MD
(left), at the House of Delegates.
Newly elected president Douglas M. Costabile, MD, and friends
(left to right), Joanne Summa, Ruth Meininger, Irene Rosenthal,
and Andrea Donelan, welcome guests.
Enjoying his inaugural dinner-dance, President Douglas Cos-
tabile, MD (standing), greets family and friends.
Palma E. Formica, MD (right), immediate past-president, honors
Paul J. Hirsch, MD (left), with the presidential gavel.
John B. McGinty, MD, president of the American Academy of
Orthopedic Surgeons, addresses the MSNJ House of Delegates.
Donald Holtzman, MD (left), chairman of the Committee on
Annual Meeting, presents a gift to Mrs. Jane Lorber, the new
MSNJ Auxiliary president.
VOL. 87— NUMBER 8 AUGUST 1990
669
MSNJ ANNUAL MEETING
MSNJ President-Elect Joseph A. Riggs, MD, addresses the House of Delegates
at the Annual Meeting.
William E. Ryan, MD, first vice-president, presents his ideas to the MSNJ House
of Delegates.
Joel S. Cherashore, MD, a member of the MSNJ Board of Trustees, comments
on his new role as AMA alternate delegate.
Second vice-president, Joseph N. Micale,
MD, greets attendees of the MSNJ Annual
Meeting.
A. Ralph Kristeller, MD, acknowledges his
new position: AMA alternate delegate.
670
NEW JERSEY MEDICINE
MSNJ ANNUAL MEETING
Michael H. Bernstein, MD, chairs Reference Committee B at the
MSNJ Annual Meeting.
Paul J. Hirsch, MD (left), presents a Golden Merit Award to one
of the recipients of this honor at the MSNJ Annual Meeting.
Elected to the Council on Membership Services, Donald J.
Cinotti, MD, addresses the members of MSNJ. Douglas M. Costabile, MD, visits the Exhibit Hall at the MSNJ
Annual Meeting.
Frank L. Redo, MD, offers his thoughts after being elected a
member of the Committee on Finance and Budget.
The general medical session, "Identification and Management
of Asymptomatic HIV-Infected Persons in New Jersey,” con-
cludes the MSNJ Annual Meeting.
VOL. 87— NUMBER 8 AUGUST 1990
671
MSNJ ANNUAL MEETING
The officers of the MSNJ Auxiliary: (seated left to right): Jean Taboada, president-elect; Jane Lorber, president; Joan Gering,
vice-president; Dorothy Espinola, recording secretary; (standing, left to right): Dorothy Praiss, corresponding secretary; Marion
Geib, treasurer; and Chris Kline, director.
672
NEW JERSEY MEDICINE
EDITORIAL CRITERIA
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
vision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statement accompany-
ing material offered to NEW JER-
SEY MEDICINE must contain the
following language and must be
signed by all authors.
“In consideration of NEW JER-
SEY MEDICINE taking action in
reviewing and editing my sub-
mission, the author(s) undersigned
hereby transfers, assigns, or other-
wise conveys all copyright own-
ership to the Medical Society of
New Jersey, in the event that such
work is published in NEW JER-
SEY MEDICINE.
Specifications. Submit two
manuscripts that must be type-
written and double-spaced on 8V2"
by 11" paper. Statistical methods
should be identified.
Authors are asked to seek clar-
ity, accuracy, and originality; at-
tention to details of grammar,
spelling, and typing are important.
The title page should include the
full name, degrees, and affiliations
of all authors, and the name and
address of the author to whom re-
print requests and correspondence
should be sent.
The author should submit a 30-
word abstract.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission must be
submitted.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote
with the first use of the generic
name. Proprietary names of de-
vices should be indicated by the
registration symbol — ®.
References should not exceed 35
citations except in review articles,
and should be cited consecutively
by numbers in parentheses at the
end of the sentence. The reference
list should be typewritten and
double-spaced on separate 8V2" by
11" sheets in numerical order. The
style of NEW JERSEY MEDI-
CINE for references is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
viewers and the authors will be
permitted, but authors will be in-
formed of the reviewers’ com-
ments. Galley proofs will be sub-
mitted to the author for correction.
Reprint Orders. Reprints may be
ordered after the author is notified
that the article has been selected
for a specific issue. A check for the
cost of reprints must accompany
that order.
Communications. All com-
munications should be sent to the
editor, NEW JERSEY MEDI-
CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
VOL. 87— NUMBER 8 AUGUST 1990
673
1990 TRANSACTIONS
Medical Society of New Jersey
674
NEW JERSEY MEDICINE
Table of Contents
Reference Committee “A”
President/Chairman of the Board of Trustees Tr 3
Judicial Council Tr 6
AMA Delegation Tr 7
Committee on Long-Range Planning and Development Tr 12
Committee on Physicians’ Health Tr 14
Resolution #6: Medical Staffs Tr 16
Resolution #13: Right To Prescribe the French “Abortion Pill” Tr 17
Resolution #14: Good Samaritan Immunity Tr 18
Resolution #15: Tax Deductions for Uncompensated Care Tr 19
Resolution #16: No to National Health Insurance Tr 20
Members: Om P. Sawhney, MD, Chairman; Anthony P. Caggiano, Jr, MD;
Robert C. Emery, MD; Robert S. Rigolosi, MD; William V. Harrer, MD, Alternate
Reference Committee “B”
Secretary Tr 21
Treasurer Tr 23
Committee on Finance and Budget Tr 25
Council on Mental Health Tr 28
Council on Public Health Tr 29
Committee on Annual Meeting Tr 30
Nominations for Emeritus Membership Tr 31
Supplemental Reports Tr 32
Resolution #1: HIV Infection as a Communicable Disease Tr 34
Resolution #4: Regulation of Office Laboratories Tr 34
Resolution #5: Realistic Child and Scholastic Athletes’ Benefits Tr 35
Resolution #27E: HIV Testing for Hospital Admissions Tr 36
Resolution #28E: Increased Exemptions from CLIA 88 on a Specialty
Specific Basis Tr 37
Members: Michael H. Bernstein, MD, Chairman; Churchill L. Blakey, MD;
Russ C. Camangian, MD; Frederick G. Dalzell, MD; David J. Greifinger, MD;
Gabriel F. Sciallis, MD, Alternate
Reference Committee “C”
Council on Medical Services Tr 38
Resolution #3: Third-Party Reviewers Tr 39
Resolution #7: Objection to HCFA Administrative Policies Tr 40
Resolution #8: Objection to Physician Requirement To Fill Out Claims for
Medicare Beneficiaries Tr 41
Resolution #9: Objection to Malpractice Surcharge Tr 41
Resolution #10: Limited Endorsement of Suppliers of Membership Services Tr 42
Resolution #11: Medicare Billing Tr 43
Resolution #12: Prescriptions in Nursing Homes Tr 44
Resolution #17: Frivolous Suits Tr 45
Resolution #18: Replacement of Medicare Carrier Tr 46
Resolution #19: Qualifications of Experts in Medical Malpractice Cases Tr 46
Resolution #20: Formation of a Counter Litigation Society Tr 47
Resolution #21: Clarify Medicare Definition of Medically Unnecessary Services Tr 48
Resolution #26E: Medicare Physician Toll-Free Telephone Service Tr 49
Members: Lawrence Frieman, MD, Chairman; J. Gerard Crowley, MD;
Matis A. Fermaglich, MD; Harold R. Reeve, MD; Harry M. Woske, MD;
Louis G. Fares, II, MD, Alternate
NEW JERSEY MEDICINE Tii
Reference Committee “D”
Council on Public Relations Tr 50
Council on Legislation Tr 52
Supplemental Reports Tr 56
Resolution #2: Alternative to Tort Reform Tr 67
Resolution #23E: Oppose Physician Assistants Tr 68
Resolution #24E: Representation on Governor’s Commission on Health
Care Costs Tr 69
Resolution #25E: Information Regarding Health Care Costs Tr 70
Members: Ian Samson, MD, Chairman; Terry A. Johnston, MD; Philip A. Rispoli, MD;
Bessie M. Suilivan, MD; Saul M. Tischler, MD; Richard R. Lorber, MD, Alternate
Reference Committee on Revision of Constitution and Bylaws
Committee on Revision of Constitution and Bylaws Tr 71
Resolution #22E: Term of AMA Delegates and Alternates Tr 73
Members: Glenn P. Lambert, MD, Chairman; Joseph A. Lieberman, III, MD;
John H. Lifland, MD; Frank J. Primich, MD; Andrea I. Reznik, MD;
Evangelos Megariotis, MD, Alternate
Additional Materials
Memorial Resolutions Tr 74
Informational Report: Senior Citizens Task Force Tr 75
Informational Report: Task Force on the Shortage of Nurses and
Technical Personnel Tr 77
New Business Tr 79
Offices Filled by Election Tr 80
1989 Transactions
The House of Delegates approved the Transactions of the 1989 Annual Meeting, as
published in NEW JERSEY MEDICINE.
Action To Limit Debate
The House of Delegates agreed, upon motion, that no one may speak more than once
on any given subject except in rebuttal or by express permission of the House, and that floor
time in each instance shall be limited to four minutes unless exception is made by the House.
Reports and Resolutions
Reports and resolutions and the actions, thereon, are included under the Reference
Committee to which they were assigned. The House takes action only on the resolved sections
of a resolution.
MSNJ Appointments
Speaker: KarlT. Franzoni, MD, Mercer
Vice-Speaker: Edward A. Schauer, MD, Monmouth
Chief Sergeant-at-Arms: Charles J. Zwerling, MD, Monmouth
Sergeants-at-Arms: Anthony G. Barbara, MD, Bergen;
Leticia V. DeCastro, MD, Middlesex; Frank L. Redo, MD, Salem;
Robert I. Salasin, MD, Cape May
Chief Teller: George T. Hare, MD, Camden
Tr2
NEW JERSEY MEDICINE
M—romaw m— ama
President/Chairman of the
Board of Trustees
PAUL J. HIRSCH, MD
(Reference Committee “A”)
During the past year, the Medical Society of New Jersey has continued to vigorously pursue
the interests of our membership, and the interests of our patients. Our highest priority always
has been, and will continue to be, to maintain high quality and accessible care for the citizens
of New Jersey.
Crisis in Health Care. The number of patients in New Jersey with AIDS continues to climb
tragically. Our Task Force on AIDS continues to grapple with the important and sensitive issues
that arise from this awful disease. We believe that our Legislature, and the citizens of our state,
do not understand the immensity of the tragedy that awaits us, in terms of loss of life, human
suffering, and economic costs. Only partially related to the AIDS epidemic is the shortage of
nursing and other health care workers. We will continue to deal with this problem, and to
evaluate potential solutions, through our Task Force on the Shortage of Nurses and Technical
Personnel. Similarly, there is a shortage of physicians to treat AIDS patients, and some other
disadvantaged patient groups. In part, this relates to the lack of funding for medical care for
these groups, thereby depriving some patients of accessible medical care. Our Task Force on
Patient Care for the Under-Insured is developing strategies to deal with this situation. Over
the past several years, our Committee on Environmental Health has become a respected voice
among those concerned about the destruction that man may wreak on the land, the water, and
the air we breathe.
Legislative/Regulatory Activity. We cannot escape the fact that governmental activity
now impacts more strongly on the quality of care and the availability of care, than all other
factors combined. The Medical Society of New Jersey has continued to increase its participation
in the legislative and regulatory processes, on behalf of our profession and our patients.
We have learned to focus our legislative efforts in a few areas of highest priorities, and yet
maintain the flexibility to deal with “emergency” situations. Your Board has identified areas
of priority as guidelines for leadership during the next year.
During this past year, we have been particularly pleased with our success in the Legislature,
markedly reducing the medical waste regulation fee (for most physicians, lowered from $528
to $100); and of the success of the Codey legislation (S-2936) for physician licensure reform.
Although we were pleased to succeed with virtually all of our goals for this legislation, we will
continue to pursue additional improvements in the law.
The Executive Committee of the Board of Trustees went to Washington last fall, and met
with several of our congressmen, and with the health aides of every senator and congressman
from New Jersey. We also held a Board legislative seminar, attended by leaders from the New
Jersey Legislature. We have maintained close and frequent contact with our state and federal
legislators, at many intervals during the year. During the gubernatorial campaign, the leadership
of the Board of Trustees met with both candidates and their staffs. Similar and additional
contacts will be continued as part of our ongoing program of participating in the formation of
public policy affecting the health of our patients.
Litigation. The Board of Trustees recognizes that litigation is a last resort, always with
an uncertain outcome. But, we have learned that we must not hesitate to use this mechanism
when it is necessary to protect the rights of the physicians of New Jersey. We have continued
to litigate against the insurance commissioner, with regard to the professional liability surcharge.
Our initial efforts resulted in a 50 percent decrease in this surcharge for most of our members;
but we will not rest until we have eliminated this unwarranted, unfair, and unreasonable tax.
We have continued our litigation against the State Board of Physical Therapy, to prevent
the expansion of physical therapists into areas for which their education does not prepare them.
We have won this battle in the lower courts, and continue with it at the Supreme Court level.
MEW JERSEY MEDICINE
Tr3
We are involved with ongoing litigation with the PRO, to protect the full rights of our
membership to legal counsel and legal representation at all stages of inquiry by the PRO.
“Your Insurance Company.” One of the most important and far-reaching actions of the
Medical Society of New Jersey in recent memory was the formation of a professional liability
insurance company, to provide coverage for our members, and for other New Jersey physicians.
The Medical Inter-Insurance Exchange of New Jersey (MIIENJ), and its “management com-
pany,” the New Jersey State Medical Underwriters (NJSMU), have provided responsible pro-
fessional liability coverage since their inception. During the past year, MIIENJ has returned
an 11 percent refund on the 1978 premium year, to those who were insured at that time. And,
application has been made to the Department of Insurance to begin to return the nonrecourse
loans.
The Board of Trustees of the Medical Society of New Jersey remains keenly aware of its
responsibilities and obligations (on behalf of our membership) to maintain a high-quality man-
agement team for “our insurance company” and to ensure the very best possible coverage, at
the lowest price, to our members.
In 1989, six MIIENJ lawsuits resulted in adverse verdicts that exceeded $1 million. While
the company is well positioned to meet such challenges, several members of the Board of
Directors and the Board of Governors agreed that it was time to re-evaluate MIIENJ’s claim
management approach and activities. A special study through the consulting firm of Tillinghast
was conducted. The consultants performed a thorough review, and presented their findings and
recommendations to the Board of Directors. Tillinghast concluded that top priority should be
given to a search for the president’s position vacated by Peter Sweetland’s retirement due to
illness; that has begun. The study team also recommended revised policies for claim manage-
ment, improved strategies, utilization of attorneys and experts, and several proposals to enhance
performance and evaluation. Additionally, the study offers several proposals for increasing
management and Board oversight to ensure proper control of claim management.
We intend to deal honestly and forthrightly with the recent Tillinghast consultation report,
to the betterment and improvement of service to our members, and all insureds. In order to
add to the strength of the company, and of the relationship, the Board of Trustees has added
five new members to the Board of Directors of NJSMU.
Strategic Planning. We have initiated a process of long-range and strategic planning for
the Medical Society of New Jersey, including a Board of Trustees retreat. We believe this process
will provide continuity and consistency, as well as programming for change and maintaining
our options to meet the challenges and opportunities of the future.
Medicare/Pennsylvania Blue Shield (PBS). For more than a year, the Medical Society
of New Jersey has had ongoing meetings with Pennsylvania Blue Shield and the Health Care
Financing Administration (HCFA) to iron out difficulties between PBS and physicians. Rep-
resentatives from PBS generally attend the monthly meetings of the MSNJ Board of Trustees.
The ICD-9 coding problems improved dramatically when PBS agreed to send a notice to
all physicians, with specific instructions regarding correlation of the procedure code and the
diagnosis code. With regard to global billing, PBS agreed to reimburse for consultations following
a procedure, if this were legitimately a separate event; all prior claims were reprocessed without
the need for additional action on the part of the physician.
An additional problem arose with the need to enter the referring physician’s provider
identification number, and PBS was not willing to issue the numbers to all physicians. This
was brought to HCFA at the insistence of MSNJ; after some months, PBS prepared a directory
listing all physician Medicare provider numbers, and sent this to all New Jersey physicians.
When Pennsylvania Blue Shield announced it would discontinue its 800 number for phy-
sicians calling PBS, complaints by MSNJ led to the indefinite continuation of this service.
An important remaining issue is the assistant at surgery. PBS and HCFA have remained
adamant on this issue. We are hopeful that this issue can be resolved after review by the State
Board of Medical Examiners.
Physician Unity. Our successes depend upon the unity of the physician community of New
Jersey. The Medical Society of New Jersey is the appropriate organization for physician unity
in New Jersey.
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NEW JERSEY MEDICINE
During the past year we have provided a seat at our Board of Trustees for a representative
of the New Jersey Association of Medical Specialty Societies and for a representative from the
New Jersey Hospital Medical Staff Section. We believe this has provided an additional voice
for other physician groups, and has strengthened your Medical Society. But, further and more
formal steps also must be taken in the future, to ensure our progress toward the goal of physician
unity.
Communication. One of our most important priorities has been to continue to improve
communication with our members. Frequent and effective communication in both directions
is necessary for the success of all of our other programs. During the past year, we have increased
the use of the “MSNJ Hotline,” for fast communication of important events. The “Capitol
Commentary,” a part of NEW JERSEY MEDICINE , now is sent separately so that you receive
this information earlier, and in an easily readable format. A new first page (“Newswatch”) has
been added to NEW JERSEY MEDICINE ', with a “closing date” of only five days before
publication, to additionally bring to you the latest information in all areas.
We also communicated with the leadership of the New Jersey medical community, at the
Conference of Presidents, in November 1989. This meeting provided an update for your leader-
ship, regarding legislation, regulation, litigation, Medicare, and other topics of importance. This
was successful and well received; it will be continued, with consideration given to increasing
the frequency to twice each year (September and January).
Further communication occurs with attendance at your local meetings. All recent presidents
of the Medical Society of New Jersey have been eager to attend county medical society meetings
when invited. This is an opportunity for your leadership to discuss the activities of the Society
and, more important, to hear what the membership has to say. The president of the Society,
and all members of the Board of Trustees, are available at your request. It is an essential aspect
of our two-way communication.
The Board of Trustees is particularly proud of the communication that exists each month,
at our open Board meetings. These meetings are open to every member of the Medical Society
of New Jersey. Any member may comment on any issue or item before the Board. Any member
may request that an item be placed on our agenda. Individual members can, and frequently
do, affect and change the decision-making process. Attendance at these meetings is the very
best means of all of staying informed about the issues that affect your practice and having direct
input on the decisions made by your Board.
Conclusion. To review any year in the course of our Medical Society is to review but a
small segment of a continuum of an ongoing process guided by your elected representatives on
the Board of Trustees. I personally am grateful for having had the opportunity to work with
the dedicated and hardworking members of this Board, and I appreciate their commitment to
our Society, and their concern for the quality of medical care in New Jersey.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
NEW JERSEY MEDICINE
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Judicial Council
PAUL H. STEEL, MD, CHAIRMAN
(Reference Committee "A”)
From official findings, the Judicial Council presents a summary of its operations and those
of county judicial committees for the period March 1989 through May 1990.
By Judicial Committees
Complaints reported as disposed of 80
Alleging:
Dissatisfaction concerning fees 40
Dissatisfaction concerning medical procedures 15
Unprofessional conduct 10
Dissatisfaction concerning professional ethics 15
By Judicial Council
Meetings held 2
Official communications acted upon 125
Appeal hearings requested 1
Appeal hearings granted 1
Formal opinions revised (Opinion #14) 1
Interest Charges. Revised February 16, 1990. A physician who has experienced problems
with delinquent accounts may properly choose to add interest or other reasonable billing charges
to delinquent accounts. The patient must be notified in advance of the interest or service charges
by means of posting a notice in the waiting room, the distribution of leaflets in the office, and
appropriate notations on billing statements. The physician must comply with state law that
limits interest to the rate approved by the State Supreme Court. The rates may be obtained
by calling the State Division of Investment (609/984-4187). The approved rate changes annually.
The rate until June 1990 is 8 percent. Physicians are encouraged to make exceptions in hardship
cases. The Council does not believe it is appropriate to add attorneys fees, court costs, or
collection costs to the amount owed.
A number of inquiries have been received concerning the appropriateness of forwarding
third-party fee complaints to specialty societies for their consideration.
For information to the membership, Opinion #11 adopted by the Judicial Council on October
14, 1981, and reissued on August 5, 1987, is presented in full and made a part of its 1990 Annual
Report as follows:
Propriety of judicial committees forwarding third-party fee complaints to specialty
societies for their consideration. The Bergen County Medical Society has questioned whether
it is appropriate to forward third-party fee complaints to specialty societies for their consider-
ation. The question also was raised regarding an administrative review fee by the specialty
societies.
The Council recognizes that fee questions can sometimes require referral to a specialty
society. It is, indeed, appropriate for a judicial committee to refer such a question for expert
opinion or advice, bearing in mind that the judicial committee is to make the final determination.
If the specialty society requires that a modest administrative fee, i.e. $25 to $50 be paid
by the third party, the Council views that situation as being within reasonable bounds.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
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NEW JERSEY MEDICINE
AMA Delegation
KARL T. FRANZONI, MD, CHAIRMAN
(Reference Committee “A”)
The composition of the AMA House of Delegates now totals 435 delegates.
The agenda dealt with by the House continues to expand and broaden. The issues that
require attention, debate, resolution, and policy pronouncements sometimes appear limitless.
In response to the question, “What does the AMA do for me?” the following accomplish-
ments are worth citing:
1) The defeat of mandatory assignment four times in the past three Congresses.
2) The fact that the AMA is the world’s largest publisher of scientific information.
3) The defeat of expenditure targets in the budget bill.
4) The AMA’s commitments to National Institutes of Health funding to protect the stability
and integrity of medical research in the United States.
5) The AMA’s considerable activities in communicating medicine’s story to the public
including: weekly news releases to 3,000 reporters, meetings with editorial boards, American
medical television reaching over 50,000 physicians and 800,000 lay people each month, and
American medical radio news used by 500 radio stations daily.
The AMA represents the national spokesperson of our revered profession. All of us should
commit to the active recruitment of our confreres who currently are not AMA members.
MSNJ RESOLUTIONS BEFORE AMA HOUSE OF DELEGATES
The following deals with resolutions introduced by the Medical Society of New Jersey in
the AMA House of Delegates.
1. Sexual Exploitation. The resolution introduced by the New Jersey Delegation asked for
reaffirmation by the AMA that sexual exploitation in teaching and other professional rela-
tionships is unethical and unprofessional.
Although the resolution was not adopted, Report B of the AMA Council on Ethical and
Judicial Affairs was adopted in its place.
Report B of the Council on Ethical and Judicial Affairs defined sexual harassment as it
may occur in medical training programs, and recommended that all medical training programs
have a policy on sexual harassment and consensual sexual relationships, and that a grievance
procedure should be in place to protect the rights of both trainees and educators.
2. Removal of Discriminatory or Biased Provisions Toward Nonparticipating Phy-
sicians. The resolution introduced by the New Jersey Delegation urged that the AMA petition
Congress, the Health Care Financing Administration (HCFA), and Part B carriers to remove
all factors that discriminate against nonparticipating physicians in Medicare; and further, that
the AMA petition Congress, HCFA, and Part B carriers to ensure that explanation of benefits
to beneficiaries states nothing more than the reimbursement allowed for medical services.
The House adopted a substitute resolution submitted by the reference committee that asked
that the AMA seek to remove, on the Explanation of Medicare Benefits sent to the patients
of Medicare nonparticipating physicians, all statements regarding the participation status of
the physician and the alleged benefits associated with the assignment of claims from seeing
participating physicians.
In addition to lobbying key committee members and staff, a letter was sent to U.S. Represen-
tative Butler Derrick (South Carolina) supporting his draft bill to repeal the participating
program.
3. Mandatory Medicare Assignment or Determination of Fee Levels. The resolution
proposed by the New Jersey Delegation asked the AMA to petition Congress to mandate that
no state be allowed to legislate that physicians’ acceptance of Medicare assignment or the
Medicare allowance of reimbursement be a condition of medical licensure.
NEW JERSEY MEDICINE
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The Reference Committee offered a substitute resolution asking that the AMA vigorously
oppose any federal legislation that would mandate Medicare assignment; and that the AMA
seek federal legislation that would prohibit states from enacting legislation to require that
acceptance of Medicare assignment or the Medicare allowance of reimbursement be a condition
of medical licensure, or used in determinations of unprofessional conduct, or made effectively
mandatory in any other fashion.
The first section of the substitute resolution was referred to the Board of Trustees and is
under consideration and study. The second portion of the substitute resolution was adopted.
In addition to lobbying key committee members and staff, the AMA Council on Legislation
drafted, and the Board of Trustees approved, a bill to implement the second resolve.
4. Inadvisability of Medicare Participation. This resolution called on the AMA to petition
Congress to end the Medicare participation program, to oppose discriminatory policies aimed
at Medicare “nonparticipants,” and to support the right of every physician to make his own
judgment regarding the participation program.
Medicare Participation
Resolved, that the AMA petition Congress to end the Medicare “participation” program
because it is not in the best interest of physicians or their patients; and be it further
Resolved, that the AMA oppose the discriminatory policies regarding Medicare “nonpartici-
pants” being used by the government; and be it further
Resolved, that the AMA support the right of every physician to make his or her own
judgment regarding the participation program.
The action of the AMA House was communicated to Congress.
5. Humane Admission Denials. The resolution asked the AMA to request the Health Care
Financing Administration to refrain from issuing denials and termination of Medicare benefits
with respect to fragile elderly patients whose hospital stays are appropriately justified by social
need.
This resolution was referred to the Board of Trustees for action and report to the House
of Delegates at the 1989 Interim Meeting.
In its report to the House of Delegates (1-89), the Council on Medical Service addressed
the issues raised by the resolution. The report first discussed the problem of those Medicare
beneficiaries who present for care without a clear diagnosis and who require hospital admission
to allow adequate diagnosis, stabilization, or treatment. The Council recommended and the
House approved efforts to assure Medicare reimbursement for such short-term admissions when
needed in the judgment of the attending physician. It was stated that HCFA was considering
an instruction to fiscal intermediaries and PROs clarifying their responsibilities in these situ-
ations. Recent discussions with HCFA representatives have indicated no new developments. The
Council will continue to pursue with HCFA an appropriate instruction to fiscal intermediaries
and PROs so that all short-term admissions that extend beyond the 24-hour limit can be
reimbursed on an inpatient basis when documented as medically necessary for adequate
diagnosis, stabilization, or treatment.
In the same report, the Council noted that for patients who do not require or who no longer
require the intensity of services available only in a hospital setting, development of a home health
care treatment plan often is the best alternative. Home health care services can include part-
time or intermittent nursing care; physical, occupational, or speech therapy; and certain social
and home health aide services provided in connection with the patient’s condition.
Medicare coverage for home health services was expanded under the Medicare Catastrophic
Coverage Act of 1988 (PL 100-360). The program now will pay for home health care services
for up to six days a week on an indefinite basis and for seven days a week for up to 38 days,
when such services are furnished under a plan of care that is established and periodically
reviewed by a physician. Since 1980, no prior hospitalization has been required to establish
eligibility for home health care. Home health care can be prescribed for patients who are
homebound and who need skilled nursing care following outpatient diagnostic or therapeutic
procedures. To help assure access to this service by Medicare beneficiaries, the AMA currently
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NEW JERSEY MEDICINE
is participating in a newly established HCFA advisory committee to study ways of improving
the process of eligibility determination for home health care.
Other services also have been expanded for Medicare beneficiaries who require less than
the level of care available only in the hospital. The accessibility of skilled nursing facility (SNF)
care is improved under the 1988 Catastrophic Coverage Act, that extended SNF coverage from
100 to 150 days per year, eliminated the three-day prior hospitalization for coverage, and limited
beneficiary coinsurance payments to the first eight days of care.
The Council recognized that some elderly persons have special needs for which none of the
above services represents an appropriate or accessible choice. However, the Council believes that
the use of acute care hospitals and other medical care facilities to provide essentially supportive
or social services for such individuals is contrary to the intent of the Medicare program, which
is to finance services that are “necessary for the diagnosis or treatment of illness or injury.”
The use of such facilities for supportive or social services — particularly in the present climate
of fiscal austerity — is a disservice to those patients who depend on the program for their medical
care.
To help meet the needs of the infirm elderly who require supportive services of an intensity
less than that available through the resources previously described, the AMA Board of Trustees,
the Council on Medical Service, and the Council on Legislation have developed proposals for
improving the financing of long-term care through expansion of eligibility for Medicaid, incen-
tives to purchase private long-term care insurance through asset protection, and tax concessions
to encourage family caregiving.
6. Collective Bargaining. The resolution requested that the AMA seek the necessary
amendments to federal law to permit private practitioners to collectively bargain.
In lieu of the New Jersey resolution, the AMA House adopted Board of Trustees Report
YY. The report updates the House on the AMA’s efforts to assist physicians and medical societies
in negotiations with others. Specifically, the report describes the establishment of the Physicians
Negotiation Advisory Office. It outlines the office’s activities that relate to antitrust issues, as
well as collective negotiation matters. The report also reviews several instances where the AMA
has intervened on behalf of physicians with respect to various antitrust issues, and states that
the AMA will explore legal action against third-party payors using unfair market power against
physicians, as well as the Board’s planned consideration of legislation amending the National
Labor Relations Act to protect physicians’ right to negotiate collectively where appropriate and
necessary.
The House also adopted a resolution calling upon the AMA Board of Trustees to investigate
the matter of third-party payor anticompetitive activity and initiate any needed action to achieve
fair competition and a more level playing field between bulk purchasers of health care services
and the providers of those services, and to report its conclusions and actions to the House at
the 1989 AMA Interim Meeting.
Board of Trustees Report V (1-1989) indicated that the AMA’s Center for Health Policy
Research is in the process of identifying those payors whose market position may enable them
to engage in anticompetitive practices. Once these payors have been identified, the AMA will
contact local medical societies to determine whether the payor may be exercising market power
in an unfair manner. If so, the AMA will pursue remedies on behalf of the physicians affected.
The AMA will pursue several avenues of relief, including direct negotiation with the payor within
the limitations established by law, administrative actions with the state insurance commission,
and, if necessary, legal action in the courts.
7. ICD-9-CM Coding. The resolution introduced by New Jersey asked the AMA to seek
the repeal of the ICD-9-CM diagnostic coding requirement for physician services under Medicare.
The House adopted a substitute resolution that called on the AMA to support legislation
to repeal or substantially ameliorate the threat of federal civil money penalty liability for failure
to utilize ICD-9-CM coding in the filing of Medicare claims; that the AMA seek amendments
to the quasi-criminal Medicare civil money penalty process by providing those charged with
civil offenses the same rights now available to defendants in criminal proceedings; that the AMA
make every effort to assure that HCFA’s implementation of the coding requirement be under-
taken with a view to minimizing compliance difficulties to physicians and their office staffs;
NEW JERSEY MEDICINE
Tr9
and that the AMA review all other Medicare civil monetary penalty provisions, assess the
physicians to challenge civil fines levied against them, and report its findings and recommen-
dations to the House of Delegates at the 1989 AMA Interim Meeting.
The AMA informed Health Care Financing Administration representatives that it would
be requesting Congress to repeal the ICD-9-CM coding requirement. The AMA position has been
communicated to Congress during the catastrophic repeal debate. A draft bill was adopted by
the AMA Board of Trustees at its October 1989 meeting.
FISCAL IRREGULARITIES OF AMA
(1) Background. In October 1989, the AMA received an inquiry from the news media
concerning certain AMA financial matters, and an investigation was begun by AMA staff.
One of the financial matters concerned a 1987 payment by the AMA to Whalen M. Strobhar,
who was chief operating officer of the AMA for more than 20 years. On October 15, 1987, Mr.
Strobhar informed Mr. John E. Turner of AMA Advisors that money from his executive variable
benefit plan money market investment had been transferred into the stock market, and de-
manded that it be returned to the money market fund. He contended that the AMA had made
an error in the transfer and that he deserved to be made whole for losses he incurred in the
stock market decline. Because transfers were allowed only at the end of the month, Mr. Strobhar,
with Mr. Turner’s support for the claim of error, sought and received approval from James H.
Sammons, MD, AMA executive vice-president, for a mid-month transfer and reimbursement
for his losses based upon the claim of AMA error. Mr. Strobhar was reimbursed $353,826 and
the AMA Board of Trustees was not informed of the transaction.
The results of the staff investigation of this incident, including facts contradicting Mr.
Strobhar’s claims, were presented via a conference call to the AMA Board by Doctor Sammons
and the AMA general counsel on October 26, 1989.
On October 27, 1989, Mr. Strobhar resigned and indicated he would repay the money, with
interest.
The second financial matter concerned a November 19, 1989, Chicago Sun-Times article
disclosing that a loan had been authorized by Doctor Sammons to a deputy executive vice-
president, Richard A. Noffke, for the purchase of a home. The AMA secured the loan with a
mortgage on the home. Mr. Noffke later terminated his employment with the AMA and received
sizeable termination pay. He failed to pay the loan as required and the AMA foreclosed on the
loan. The property was sold with a possible loss of about $50,000. Again, the AMA Board of
Trustees was not informed of the loan or the foreclosure litigation.
(2) Action of House of Delegates. The Board of Trustees Report QQ was received by the
AMA delegates for review before it was referred to Reference Committee F.
Doctor James S. Todd, AMA, senior deputy executive vice-president, presented his views
to the New Jersey delegation. He feels these were two unfortunate events; no further events
are anticipated; nothing illegal or immoral was done; the staff and auditor were aware of the
activities; and Doctor Sammons should have informed the Board of Trustees.
The following actions have been taken by the AMA Board to assure the continued exercise
of its fiduciary responsibilities:
• An independent investigation is being conducted; external accountants will undertake a
comprehensive review of financial controls of the AMA.
• No financial arrangements are to be made with any employees by the executive vice-
president.
• Accepted the plan for the executive vice-president, Doctor Sammons, to retire on March
31, 1991, and to assure an orderly transition in administrative leadership, is developing a search
process immediately to initiate a search for a successor to the position.
• The Board will formulate and institute specifically defined limits upon the authority of
the executive vice-president in respect to monetary, compensation, and health policy matters
to conform to the exercise of the Board’s fiduciary responsibilities.
There was a great deal of discussion of Report QQ at Reference Committee F. Doctor
Sammons attended the reference committee and answered many questions.
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NEW JERSEY MEDICINE
The report and the recommendations of the American Medical Association Board were
accepted by the House of Delegates.
On December 23, 1989, Whalen Strobhar returned the full amount of money, with interest,
to the AMA.
On February 9, 1990, Doctor Sammons resigned and Doctor James S. Todd was named
acting executive vice-president.
PROSPECTIVE ISSUES OF INTEREST
RBRVS: Currently returned to “drawing board” for additional development. Concept
persists viable. No definite AMA commitment to approval at this time.
Practice Parameters: Concept being developed by many specialty societies under AMA
sponsorship. Retention of physician autonomy in clinical decision making has been and will
remain “linchpin” of AMA policy. The specter and concern of “cookbook” medicine has been
expressed. The long-range answer in this issue is likely to be found between the extremes of
“none” and “too many.”
Dues: Remain at $400 for 1990; $25 to $30 increase for 1991 likely.
Pam Formica, MD. Our own Palma Formica, MD, is a candidate for election to the AMA
Board of Trustees during 1990. She possesses admirable qualities and experience to qualify for
success in her quest for this prestigious national office. Your delegation members are working
assiduously to support her candidacy and accomplish her election.
The Reference Committee recommended that the report be filed with the additional com-
ment that AMA dues will not be raised this year.
HOUSE ACTION: Adopted. The report was filed with one additional comment.
NEW JERSEY MEDICINE
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Committee on Long-Range
Planning and Development
BERNARD A. RINEBERG, MD, CHAIRMAN
(Reference Committee A)
The Committee on Long-Range Planning and Development was charged to develop goals
and objectives for a strategic plan to be utilized as a guide for the Medical Society as it enters
the 21st century. The Committee met on July 19, 1989, September 19, 1989, November 14, 1989,
and January 30, 1990. On March 9, 1990, the Committee and members of the Board of Trustees
attended a Strategic Planning Retreat to discuss, add, and delete items from the Committee’s
proposed plan. The Board of Trustees, at its April 8, 1990, meeting, approved the following goals
and objectives:
A. Professionalism. The Medical Society of New Jersey’s goal is to assist the physician
in achieving high-quality care for all individuals by supporting activities that strengthen the
patient/physician relationship while striving for efficiency and cost effectiveness. To accomplish
this, the Medical Society of New Jersey will:
1. Monitor our state’s health care needs to assure physician availability to all individuals.
2. Advise and assist public and private agencies in the development of policies and programs
designed to meet the needs of patients.
3. Encourage our state medical schools to attract the highest quality of medical student
and support programs to recruit and retain the best qualified physicians for New Jersey.
4. Encourage activities that will foster recruitment and retention of nurses and medical
support personnel.
5. Support practice management programs to improve physicians’ managerial and adminis-
trative skills.
6. Support activities that will decrease physician exposure in matters of professional lia-
bility.
7. Develop and promote programs to inform physicians of computer and information tech-
nology.
8. Support activities that will promote and develop physician leadership skills.
B. Unity. The Medical Society of New Jersey should strive to achieve unity among all
physicians. To accomplish this, the Medical Society of New Jersey will:
1. Promote open communication and debate to establish common ground among all phy-
sicians.
2. Support and develop activities that, will address the specific needs of physician groups
within the total membership.
3. Increase communication with and actively support medical specialty societies in those
endeavors that foster unity within the profession.
4. Continue to offer unique membership services to encourage new members and to retain
older members.
C. Organizational Structure. The Medical Society of New Jersey must maintain a strong
state organization with active input to and from county medical societies, state specialty so-
cieties, and national organizations. To accomplish this, the Medical Society of New Jersey will:
1. Create a review process within the organizational structure that will coordinate activities
and promote greater efficiency.
2. Encourage state society, county societies, and state specialty societies to function as
resource centers of medical information for physicians, patients, and other organizations.
3. Encourage consistent standards of admission for membership that are expeditious and
fair.
4. Encourage active participation in the activities of the American Medical Association.
5. Establish a mechanism that actively would examine councils and committees to de-
termine their efficiency in meeting assigned responsibilities.
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NEW JERSEY MEDICINE
6. Strengthen and enhance the relationship with the Medical Inter-Insurance Exchange of
New Jersey and the New Jersey Medical Underwriters, Inc. and closely monitor the quality of
services offered to our members.
D. Quest For Quality. The Medical Society of New Jersey should continue to encourage
physician participation in educational programs that will improve the quality of care rendered
patients. To accomplish this, the Medical Society of New Jersey will:
1. Encourage medical research in New Jersey.
2. Monitor physician competency and offer activities to assure quality care.
3. Seek out physicians who are impaired and provide treatment and support.
4. Create procedures that will assure adequate and worthwhile peer review.
5. Support a professional environment that will attract quality physicians to practice in
New Jersey.
E. Communication and Public Relations. The Medical Society of New Jersey should
provide information and timely advice to physicians, the public, the legislature, and the media
on matters that will affect the health and well-being of the people of New Jersey and the way
medicine is practiced. To accomplish this, the Medical Society of New Jersey will:
1. Encourage development of a mechanism at the state, county, and state specialty society
levels, when appropriate, that will ensure prompt, timely, and unified response to issues.
2. Encourage activities that will have a favorable impact on the welfare and health of the
public.
3. Encourage development of a communication system whereby physicians will be kept
abreast of the ever-changing regulations affecting their practices.
F. Legislation. The Medical Society will monitor legislation and regulations that may
impact on the welfare and health of the public, and will participate in the formulation of health
policy and of public policy that may impact on the health of our patients and the practice of
medicine, particularly as it affects accessibility, quality, costs of health care, and funding of
research and education. To accomplish this, the Medical Society of New Jersey will:
1. Review the responsibilities and directions of the Medical Society in its deliberations
regarding proposed legislation, as the “key man” program, and county involvement in legislative
process as a means to assure expeditious and timely input on legislative concerns.
2. Develop a mechanism of notification to the membership of legislative issues that will
assure that the Medical Society’s position is reflective of the membership’s concern.
3. Continue to encourage and utilize the auxiliary of its active participation in legislative
programs and issues.
It is suggested that the Board of Trustees and the Committee on Long-Range Planning and
Development meet at regular intervals (annually or biennially) to survey the progress of the
Society in meeting the goals and objectives as outlined in its strategic plan.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
NEW JERSEY MEDICINE
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Committee on Physicians’ Health
THOMAS J. LIDDY, MD, CHAIRMAN
(Reference Committee “A”)
Following are some of the Program activities for the past year:
1. Revisions to the Medical Practice Act. The major event of this past year has been the
successful collaboration between the Medical Society of New Jersey and Senator Codey’s office
to develop a new Medical Practice Act. MSNJ employed Judge Herbert Stern to represent us
in negotiations with the Senator to help develop a bill that creates a much more reasonable
basis for State Board decisions in disciplinary matters. While we did not gain all that we sought,
the changes achieved are quite significant.
2. Confidentiality. Attempt was made this year to subpoena the complete chart of an
alleged client who was party to a malpractice suit. Counsel was obtained and MSNJ was
successful in citing federal regulations prohibiting the release of such information without the
plaintiff showing evidence of a clear need to know.
3. American Medical Association. Program staff learned that the AMA did not budget
for the Department of Substance Abuse to deal with impaired physicians’ programs and phy-
sicians’ health programs for 1990. With cosponsorship by New Jersey’s Delegation to the AMA,
a resolution was adopted by the AMA House of Delegates calling for the AMA to adequately
fund and maintain an impaired physicians’ program whose charges would include, but not be
limited to, promoting state medical society impaired physicians’ programs, providing technical
assistance to state programs, conducting scientific and socioeconomic research, and hosting an
annual conference to share research and exchange ideas in the field of physician impairment.
Since the adoption of this resolution, the AMA has transferred the program to another depart-
ment.
4. Seminar on Resident Stress. Residency directors and residents have been invited to
attend a two-day seminar designed to assist in dealing with the problems that surface in their
attempts to fulfill the responsibilities of a residency program. Glaxo Pharmaceutical Company
and the Physicians’ Health Program are cosponsors. The keynote speaker is Doctor John-Henry
Pfifferling, a nationally recognized authority from the Institute for Professional Well-Being in
Durham, North Carolina.
5. 1989 Adopt-a-Family Program. For the fourth consecutive year, the Physicians’ Health
Program conducted the Adopt-a-Family Program for the Holidays. This year $4,650 was dis-
tributed to needy clients and their families in addition to the distribution of toys to four children
in time for Christmas and Hanukkah. It must be noted that the Board of Trustees, seven county
societies, three auxiliaries, and individuals from both MSNJ and NJAOPS donated to this
Program.
6. Annual Raffle. The 1989 Annual Raffle was held on March 29 at MSNJ headquarters.
Gross receipts from the raffle amounted to $55,312. Expenses incurred relating to the raffle were
$11,273.54. The total net proceeds added to the grant fund was $44,038.46. The 1990 raffle will
be held during the fall.
7. Grant Fund. The Grant Fund continues to operate as a fund by which physicians and/
or their families can benefit from monies made available to them on the basis of need as a result
of the annual raffle sponsored by the auxiliaries of the New Jersey Association of Osteopathic
Physicians and Surgeons and of the Medical Society of New Jersey. There were 35 grants issued
to 23 people totalling $27,864 during 1989.
8. Treatment Loan Fund. This service of the Physicians’ Health Program continues to
provide low-interest loans to physicians and/or their families based on demonstrated need to
cover treatment and/or living expenses. The status of the Treatment Loan Fund is shown in
the Table. To date, 30 individuals have received funds from the Treatment Loan Fund.
9. Subcommittee on Alcohol and Drug Abuse. The Board of Trustees discharged the
Tr14
NEW JERSEY MEDICINE
TABLE.
Fund Balance 1/1/89 $42,671.19
Repayment of Principal 4,857.42
Interest on Loans 176.50
Donations 1,530.00
Interest on Fund 13,449.46
Other <322. 67>
Loans Issued 1989 15,149.00
Fund Balance 1/1/90 50,612.90
Total Outstanding Loans 35,985.83
Total Fund Value to 1/1/90 86,598.73
(current balance + outstanding loans)
Special Committee on Alcohol and Drug Abuse and directed that its functions be administered
by the Committee on Physicians’ Health. In order to carry out this directive and still maintain
the confidentiality of matters discussed, the Board of Trustees approved the proposal that a
subcommittee of the Committee on Physicians’ Health be appointed. The function and scope
of this subcommittee is: (a) to sponsor one alcohol and drug abuse educational program annually;
(b) to conduct an intervention training seminar annually; and (c) to act as the clearinghouse
for MSNJ on issues concerning alcohol and drug abuse. Under the subcommittee’s auspices,
the 1990 Intervention Training Seminar is scheduled to be held on May 15 and 22. The subcom-
mittee also is in the process of planning a statewide conference involving school nurses, phy-
sicians, and counselors to review the new state laws pertaining to drug problems in schools and
program development called for in the law.
10. Statistical Summary. A statistical illustration of our Program’s activities from Septem-
ber 7, 1982, through December 31, 1989, is as follows:
Statistical Report
(by year)
(September 7, 1982-December 31, 1989)
1982
1983
1984
1985
1986
1987
1988
1989
Total
Primary Impairment
Alcohol
14
40
19
31
31
18
15
22
190
Drugs
25
16
22
24
25
20
18
23
173
Psychiatric
7
18
19
19
14
15
9
18
119
Senility
1
5
3
2
—
—
1
1
13
Personality Disorder
—
1
—
—
2
1
—
2
6
Other
1
1
8
7
4
2
5
13
41
Annual Total
48
81
71
83
76
56
48
79
542
Degree
MD
41
66
61
61
67
50
42
67
455
DO
6
10
3
9
4
1
4
3
40
DVM
—
1
3
4
—
1
—
2
11
Other
1
4
4
9
5
4
2
7
36
Annual Total
48
81
71
83
76
56
48
79
542
Total male clients
488
Total female clients
54
Total all clients
542
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
NEW JERSEY MEDICINE
in 5
Resolution #6
Introduced by:
Subject:
Referred to:
Essex County Medical Society
Medical Staffs
Reference Committee “A”
Whereas, a hospital medical staff is an integral part of the hospital administration and the
medical staff plays an important role in the hospitals’ service to the community; and
Whereas, there have been numerous instances in New Jersey where the medical staff has
not been consulted on matters of vital concern to the medical staff regarding the provision of
services to the community; now therefore be it
Resolved, that the Medical Society of New Jersey offer assistance to medical staffs omitted
from the decision-making process of supplying care to the community and the public, in keeping
with American Medical Association (AMA) and American Hospital Association policy; and be
it further
Resolved, that the Medical Society of New Jersey bring to the attention of the New Jersey
Hospital Association any hospital administrators not consulting with medical staffs on major
-decisions on community care.
Resolved, that the medical staffs of New Jersey hospitals alert at the earliest opportunity
the Medical Society of New Jersey and the New Jersey Hospital Medical Staff Section of any
incidence of hospital administration not consulting with medical staffs on major decisions
affecting community health care.
The Reference Committee recommended that the second resolved of Resolution #6 be
amended to read as follows:
Resolved, that the Medical Society of New Jersey alert the MSNJ Hospital Medical Staff
Section and the New Jersey Hospital Association for intervention in any instances of hospital
administrators not consulting with medical staff on major decisions on community care.
The Reference Committee recommended that Resolution #6 be adopted as amended.
HOUSE ACTION: Not adopted. Resolution #6 was adopted as amended by the House.
Tr16
NEW JERSEY MEDICINE
Resolution #13
Introduced by: John Winslow, MD, Delegate, Essex County
Subject: Right To Prescribe the French “Abortion Pill”
Referred to: Reference Committee “A”
Whereas, the House of Delegates of the Medical Society of New Jersey, at its annual meeting
in May 1989, overwhelmingly passed an amended resolution guaranteeing a woman’s right to
make her own choice to have an abortion (termination of pregnancy) performed, provided it
is done in a medically safe manner by a competent physician, and at a safe time relatively early
in a pregnancy; and
Whereas, a French pharmaceutical company has developed a medication that, taken early
in a pregnancy, causes a safe and spontaneous abortion, with no significant side effects; now
therefore be it
Resolved, that the House of Delegates, at the annual meeting of the Medical Society of
New Jersey, approve the introduction of the French “abortion pill,” RU-486 (or similar code
number), and urge its approval by the Food and Drug Administration for conscientious prescrip-
tion use in the United States.
The Reference Committee recommended that Resolution #13 be rejected.
HOUSE ACTION: Adopted. Resolution #13 was rejected.
NEW JERSEY MEDICINE
Tr17
Resolution #14
Introduced by: Frank J. Primich, MD, Delegate, Hudson County
Subject: Good Samaritan Immunity
Referred to: Reference Committee “A”
Whereas, current proposals for payment of uncompensated physician services will further
erode our autonomy and ethical standards; and
Whereas, counter proposals have little chance of adoption in the near future; and
Whereas, the patients involved for socioeconomic, educational, and linguistic reasons — not
to mention the “lottery mentality,” — represent a medical liability high-risk group; and
Whereas, prevailing concepts of liability, beyond a financial burden, have had a devastating
effect upon physicians’ practice patterns; and
Whereas, this has generated vast defensive medicine expenditures that directly impact upon
all bill payors; now therefore be it
Resolved, that the Medical Society of New Jersey petition the state legislature to deem
physicians immune to charges of medical liability for uncompensated care, except in the case
of grossly negligent malpractice; and be it further
Resolved, that this proposal be forwarded to the American Medical Association (AMA) for
national consideration.
The Reference Committee recommended that Resolution #14 be rejected.
HOUSE ACTION: Not adopted. Resolution #14 was adopted.
Tr18
NEW JERSEY MEDICINE
Resolution #15
Introduced by:
Subject:
Referred to:
Frank J. Primich, MD, Delegate, Hudson County
Tax Deductions for Uncompensated Care
Reference Committee “A”
Whereas, there are an estimated 35,000,000 people without health insurance; and
Whereas, they are portrayed falsely as without access to health care; and
Whereas, in actuality, emergency, urgent, and a goodly amount of routine care continues
to be available, primarily through hospitals; and
Whereas, the growing costs of such uncompensated care, to a large extent, are reimbursed
to the hospitals through a devious and often misrepresented process of cost shifting; and
Whereas, physicians’ services and responsibilities in the care of such cases neither is com-
pensated, acknowledged, nor appreciated; and
Whereas, shortsighted physicians already are supporting national health insurance as a
means of obtaining something in return; and
Whereas, accompanying regulations and restrictions, through Medicaid and Medicare would
threaten further our individual freedoms to render appropriate cost-effective care to our patients;
and
Whereas, an alternative to this unacceptable proposal is vital to any meaningful resistance;
now therefore be it
Resolved, that the Medical Society of New Jersey petition the American Medical Associa-
tion (AMA) to propose to Congress that such uncompensated costs be allowable as nontaxable
deductions in the determination of physicians’ net income; and be it further
Resolved, that the public be made aware of this vast, and often medicolegal, hazardous,
and benevolent service being rendered by the medical profession.
The Reference Committee recommended that Resolution #15 be referred to the Board of
Trustees for appropriate action.
HOUSE ACTION: Adopted. Resolution #15 was referred to the Board of Trustees for
appropriate action.
Tr19
NEW JERSEY MEDICINE
QOTOPTOVC’Wn
Resolution #16
Introduced by:
Subject:
Referred to:
Frank J. Primich, MD, Delegate, Hudson County
No to National Health Insurance
Reference Committee “A”
Whereas, Medicare supporters originally overcame physician resistance through the prom-
ises of noninterference in medical decision making and patients’ freedom of choice of providers;
Whereas, those early reassurances long since have gone by the boards; and
Whereas, the American Medical Association (AMA) proposal essentially is identical to
Senator Kennedy’s “solution”; and
Whereas, Senator Kennedy’s approach to health care financing is abhorrent to most phy-
sicians; and
Whereas, much of the $80 billion cost will be shifted deviously to small businesses and
existing insurers; and
Whereas, the predictable failure of the program will result in a further undeserved “blame
shift” to health care providers; and
Whereas, after-the-fact explanations have minimal impact and little appreciable chance of
repeal or reversal; now therefore be it
Resolved, that the Medical Society of New Jersey petition the AMA to resist any national
health insurance program that makes the unattainable promise of high-quality care and free
choice for all patients; and be it further
Resolved, that the AMA be requested to propose a “two-class” system, with the government
“directly” responsible for funding the “second-class” care.
Resolved, that the Medical Society of New Jersey recognizes that the federal government
already has created a tiered system of medical care; and be it further
Resolved, that the Medical Society of New Jersey and the AMA advise the federal and
state governments that they should pay for the lowest tier of medical care.
Doctor Robert H. Stackpole, delegate from Union County, suggested the addition of the
third and fourth resolveds.
The Reference Committee recommended that Resolution #16 be rejected.
HOUSE ACTION: Not adopted. Resolution #16 and suggested amendments (the third
and fourth resolveds) were referred to the Board of Trustees.
Tr20
NEW JERSEY MEDICINE
Secretary
BERNARD ROBINS, MD
(Reference Committee “B”)
The office of the Secretary has continued its usual routines, primarily involving maintenance
of membership records, correspondence, minutes of Board of Trustees’ meetings, telephone
inquiries, and completion of numerous questionnaires originating from various sources.
During the administrative year, the Secretary attended the meetings of the Board of Trustees
and the several committees of which he is chairman, member, or advisor.
Active
Paid
Exempt....
Membership (as of December 31,
7,438
845
1989)
Resident
Paid
149
8,432
*Associate
Paid
58
**Affiliate
Paid
Exempt....
86
5
State Emeritus
Total of above
Provisional Residents (six months)
State Honorary
New and Reinstated Members
Active
Resident
* Associate
Transfers within the state
Transfers out-of-state and resignations
Members deceased
Members dropped
Active:
a. Nonpayment of dues 278
b. Did not comply with bylaw requirements regarding continuing medi-
cal education, whose credits were due in 1988 37
c. New Jersey license suspended 1
Resident (nonpayment of dues) 45
* Associate (nonpayment of dues) 20
**Affiliate (nonpayment of dues) 7
1,086
9,667
14
1
611
60
33
35
98
124
388
*Associate membership (nonlicensed in New Jersey) designates interns and residents.
**Affiliate membership designates physicians who no longer practice in New Jersey.
***Adjusted for transfers out-of-state, resignations, and deaths.
A comparison of December 31, 1988, to December 31, 1989, by county shows the following
net changes of active
paid membership:
Atlantic
+ 9
Gloucester
+ 1
Ocean
+ 1
Bergen
- 1
Hudson
- 30
Passaic
- 22
Burlington
- 9
Hunterdon
+ 1
Salem
- 6
Camden
+ 2
Mercer
- 9
Somerset
+ 6
Cape May
- 1
Middlesex
- 10
Sussex
+ 1
Cumberland
- 7
Monmouth
- 9
Union
- 8
Essex
- 26
Morris
- 5
Warren
- 7
AMA Membership. A total of 9,505 New Jersey licensed physicians maintain active mem-
AL^AL-LJ=DCCV Mcn.n.MC
Tr21
bership in the AMA. The Society’s representation in the AMA House of Delegates stands at
ten delegates — one for each thousand members, or fraction thereof.
Credentials. The Committee on Credentials reviewed and acted upon membership appli-
cations and their supporting credentials as submitted through the component societies. The
statistical breakdown reflects the Committee’s activities during the period February 1, 1989,
through January 31, 1990.
Provisional Residents
Grand
Received
*Associate
Licensed
Active
Total
33
32
415
480
Provisional
Residents
Grand
Reviewed and found
*Associate
Licensed
Active
Total
(A) Satisfactory
32
28
364
424
(B) Unsatisfactory
0
0
0
0
Pending
1
4
27
32
Withdrew
0
0
24
24
Grand Total
33
32
415
480
* Associate membership (nonlicensed in New Jersey) designates interns and residents.
The Committee extends appreciation to the directors and the secretaries of component
societies, and to those who assist them, as well as the County Credentials Committees, for their
cooperation in processing membership applications. It especially would be helpful to the Creden-
tials Committee of the Medical Society of New Jersey if those who process credentials in the
component societies would call specific attention to any deficiencies or questionable data being
submitted on the application form. This procedure will help insure more accurate and speedy
evaluation of credentials. The chairman wishes to thank his Committee members for their
diligence and cooperation.
Membership Directory. The 1989 edition of the Membership Directory has been available
for one year. Since the original distribution of 9,884 copies to members, 1,771 copies have been
sold. It is anticipated that data sheets for the 1991 edition will be mailed to members about
September 1990. Your cooperation in returning them promptly will be greatly appreciated.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
Tr22
NEW JERSEY MEDICINE
Treasurer
GERALD H. ROZAN, MD
(Reference Committee “B”)
These interim financial statements, prepared in accordance with generally accepted account-
ing principles, reflect the financial position and results of operation of the Medical Society of
New Jersey through February 28, 1990.
Since they are interim statements (the Society’s fiscal year is June 1-May 31), the figures
are unaudited. A complete audit will be conducted of the books of the Society as of May 31,
1990, and an audited report prepared as of that date. A complete audit was made, and copies
sent to all county medical societies, as of May 31, 1989.
Medical Society of New Jersey
Balance Sheet
February 28, 1990
(Unaudited)
Assets
Cash
Investment in money market fund
Marketable securities — (approximate market)
Accounts receivable — member assessments
Medical student loans (net allowance)
for doubtful loans of $20,000)
Property, Plant, and Equipment
Land $ 150,000
Building and improvements 2,563,865
Furniture and fixtures 529,496
Construction in progress 2,463,726
5,707,087
Less allowance for depreciation (1,069,228)
Prepaid expenses
Other assets
Investment in New Jersey State Medical Underwriters, Inc.
Liabilities and Fund Balance
Accounts payable and accrued expenses
Assessments collected for AMA
Loan payable to Medical Inter-Insurance Exchange
of New Jersey
Mortgage payable
Deferred revenue from member assessments
Deferred revenue — public relations assessment
Deferred revenue — other
Fund Balance
$ 81,076
1,081,098
2,839,649
502,950
195,493
4,637,859
116,676
303,079
30,367
$9,788,247
$ 408,694
24,995
433,689
2,428,253
1,334,754
2,158,359
234,665
217,098
2,981,429
$9,788,247
NEW JERSEY MEDICINE
Tr23
—BHwae
l
Medical Society of New Jersey
Statement of Revenue and Expenses
9 Months Ended February 28, 1990
(Unaudited)
Revenue
Membership dues $1,869,698
Publication sales and advertising income 208,655
Amortization of Physicians’ Health Program 187,146
Amortization of public relations assessment 82,376
Investment income 167,407
Royalty income 190,218
Rental income 389,483
Annual Meeting 32,755
Other income 51,030
Total Revenue 3,178,768
Expenses
Conferences and meetings 342,961
Member services 667,244
1,010,205
General and administrative 1,454,901
Interest 255,819
Depreciation 124,145
Total Expenses 2,845,070
Excess of revenue over expenses before federal income tax $ 333,698
Provision for federal income tax 49,898
283,800
Equity in income (loss) of unconsolidated subsidiary (621)
Excess of revenue over expenses 283,179
Fund balance at June 1, 1989 2,698,250
Fund balance at February 28, 1990 $2,981,429
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
Tr24
NEW JERSEY MEDICINE
Committee on
Finance and Budget
MATIS A. FERMAGLICH, MD, CHAIRMAN
(Reference Committee “B”)
The Committee on Finance and Budget met on Thursday, March 29, 1990, for the purpose
of reviewing the proposed budget for the 1990-1991 fiscal year. The proposed budget and the
following recommendations were approved by the Board of Trustees on April 8, 1990, and are
submitted to the House of Delegates for approval.
RECOMMENDATIONS
1. That the budget for the fiscal year beginning June 1, 1990, and ending May 31, 1991,
in the amount of $4,301,000 with $2,590,000 to be raised through member assessments be
adopted.
2. That the 1991 assessment be set at $350 per regular dues-paying member. (No change
from prior year.)
3. That the 1991 assessment be set at $60 per member for affiliate members (no longer
practicing in New Jersey). (No change from prior year.)
4. That the 1991 assessment for associate members (interns-residents nonlicensed in New
Jersey) and licensed residents, provided the individual is in a residency program entered upon
within a reasonable time after his or her graduation from medical school, be set at $25. (No
change from prior year.)
5. That the 1991 assessment be set at $10 per student for medical students. (No change
from prior year.)
The Reference Committee recommended the approval of recommendations 1 through 5.
HOUSE ACTION: Adopted. The recommendations were approved.
NEW JERSEY MEDICINE
Tr25
Medical Society of New Jersey
Statement of Revenue and Expenses
Proposed Budget
Fiscal Year Ending May 31, 1991
Revenue (other than member assessments)
Publication sales and advertising income $ 230,000
Amortization of Physicians’ Health Program 269,000
Amortization of public relations assessment 216,000
Investment income 110,000
Royalty income 262,000
Rental income 567,000
Annual Meeting 15,000
Membership Directory sales 55,000
Other income 10,000
Total Revenue $1,734,000
Expenses
Conferences and meetings 564,000
Member services 644,000
Publications 326,000
Total Program Expenses $1,534,000
General and administrative 2,237,000
Interest 359,000
Depreciation 171,000
Total Expenses $4,301,000
Amount of expenses over revenue to be raised
through member assessments (including NEW JERSEY MEDICINE
subscriptions and Annual Meeting assessments) $2,567,000
Revenue from Member Assessments
Fiscal Year Ending May 31, 1991
$350 x 7,400 members $2,590,000
Tr26
NEW JERSEY MEDICINE
Proposed Budget: Fiscal Year Ending May 31, 1991
Approved
Estimate
Proposed
Budget
for Y/E
Budget
1989/90
5/31/90
1990/91
Compensation
Salaries
$1,080,000
$1,067,000
$1,150,000
Pension plan
102,000
104,000
115,000
1,182,000
1,171,000
1,265,000
Professional Fees
Audit
21,000
27,000
23,000
Legal
50,000
125,000
100,000
Actuarial
3,000
6,000
4,000
Special consultants
10,000
6,000
8,000
84,000
164,000
135,000
Councils and Committees
Public Relations
250,000
250,000
260,000
Public Relations — special assessment
200,000
104,000
216,000
Legislation
88,000
87,000
88,000
President and Presidential Officers
75,000
75,000
75,000
AMA Delegates
87,000
91,000
88,000
MSNJ Auxiliary
25,000
31,000
30,000
Medical Education
35,000
40,000
43,000
Board of Trustees
35,000
35,000
35,000
Judicial Council
1,000
1,000
1,000
Reimbursement of reps, to mtgs.
3,000
3,000
3,000
Other Councils and Committees
50,000
40,000
45,000
Medical Student Association
12,000
5,000
10,000
Grant allocation — MIIENJ
(330,000)
(330,000)
(330,000)
531,000
432,000
564,000
Member Services
Physicians’ Health Program
342,000
342,000
387,000
Annual Meeting
120,000
120,000
150,000
Professional Liability
52,000
48,000
50,000
Membership Directory
55,000
59,000
57,000
569,000
569,000
644,000
Publication
NEW JERSEY MEDICINE
319,000
316,000
326,000
General Administrative and Operating Expenses
Building operations — (including depreciation)
701,000
694,000
713,000
Insurance
184,000
177,000
197,000
Payroll taxes
80,000
84,000
90,000
Other general office costs
299,000
235,000
367,000
1,264,000
1,190,000
1,367,000
Total
$3,949,000
$3,842,000
$4,301,000
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
NEW JERSEY MEDICINE
Tr27
I
Council on Mental Health
THOMAS R. HOUSEKNECHT, MD, CHAIRMAN
(Reference Committee “B”)
The Council on Mental Health held its ^organizational meeting on November 9, 1989. The
Council continues to monitor the matter of military psychologists prescribing drugs and psychol-
ogists doing consultations in hospitals without psychiatrists’ supervision. The Council agreed
psychiatrists should be represented on the Committee on Senior Citizens and the Governor’s
Advisory Council on Mental Health Services Planning, and the Council is working to facilitate
such appointments. The Council reviewed proposed legislation on isolation of HIV positive
psychiatric patients in state hospitals. The Council believed there was a place for isolation in
the face of active AIDS disease with the presence of severe secondary infections that could pose
a threat to hospital staff.
Several persons expressed concern about military programs permitting psychologists to
prescribe drugs and perform consultations. It was suggested that the Board of Trustees review
policy already established and act accordingly.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Not adopted. The report was referred by the House of Delegates
to the Board of Trustees for further consideration.
Tr28
NEW JERSEY MEDICINE
Council on Public Health
CHARLES J. MOLONEY, MD, CHAIRMAN
(Reference Committee “B”)
The Council on Public Health met on December 6, 1989. The Council recommended to the
Board of Trustees that MSNJ petition the governor, the commissioners of Health and of Educa-
tion, and the state legislature to intensify efforts to vaccinate unimmunized children, and to
require a second MMR vaccination for school attendance. This recommendation will be sub-
mitted to the Board of Trustees for their review at its February 18, 1990, meeting.
Resolution #4 — Tanning Salon Legislation. This resolution still is under review by the
Council on Public Health.
The Committee on Environmental Health recommended to the Council that conferences
be arranged for the members of the Medical Society of New Jersey, to educate them and to
help them understand the rules and regulations pertaining to medical waste, and that representa-
tives of the Department of Environmental Protection set up these programs through the Academy
of Medicine of New Jersey.
Also, the Committee on Environmental Health has reviewed several companies looking for
endorsement for medical waste disposal. The Committee is reviewing this in conjunction with
the Committee on Membership Services acting on Resolution #15 concerning endorsing medical
waste disposal companies.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
NEW JERSEY MEDICINE
Tr29
Committee on Annual Meeting
DONALD J. HOLTZMAN, MD, CHAIRMAN
(Reference Committee “B”)
The Committee met on September 6, 1989. It was the strong feeling of the group that the
meeting be held in Atlantic City, if at all possible. The Taj Mahal Casino Hotel could not give
us a commitment. The Sands Hotel appeared anxious for our business and the package they
offered appeared to be satisfactory. For the record, it was noted that the New Jersey Bar
Association meets there for their annual meeting, and are pleased with the facility.
As regards future meeting sites, the Taj Mahal remains a possibility. If we are treated well
at the Sands, it may be a consideration for future meetings. As more hotel facilities become
available in Atlantic City, the opportunities we will have for booking and arrangements may
be better. Any overflow activities for this meeting can be handled by the adjacent Claridge Hotel.
As regards to the schedule for the upcoming meeting, the possibility of shortening the
meeting and rearranging the schedule was felt to be unworkable. The possibility of scheduling
the reference committee meetings further apart or sequentially could not be worked out satisfac-
torily.
The schedule of the meeting, therefore, will be traditional, with the Board of Trustees’
meeting starting on Saturday, May 5, 1990. On Sunday, May 6th, registration will open for the
formal meeting and the meeting will conclude on Wednesday, May 9th. The Medical Society
of New Jersey Board of Trustees approved the convention site and meeting schedule on Septem-
ber 17, 1989.
The educational program will start at 10 A.M. Sunday morning, and the exhibits will open
at 11 A.M. The first House of Delegates will convene at 1 P.M., and then the first reference
committee meetings will be at 3:30 P.M.
On Monday, May 7th, the House of Delegates will convene at 9 A.M., when elections will
be held. The Professional Liability Program will be held at 1 P.M. on that day; later that
afternoon, the JEMPAC Political Forum followed by the wine and cheese reception are sched-
uled.
On Tuesday, May 8th, the House of Delegates will convene at 9 A.M., and again at 1:30
P.M. The Inaugural Reception and Dinner will be at 6:30 P.M., and the meeting will conclude
on Wednesday, May 9th.
The exhibit area at the Sands Hotel is separate from the rest of the hotel, and more than
satisfactory. We will be using the showroom for several of our functions including the Inaugural
Reception and Dinner.
The tentative plans for the educational aspects of the meeting include two seminars: “The
Four Complications of Diabetes,” and “Identification and Management of Asymptomatic HIV-
Infected Persons in New Jersey.”
As regards future planning, it would be wise to try and have things relatively firmed up
several years in advance. As more facilities become available, future opportunities may be
progressively more attractive.
There was mostly adverse comment concerning the choice of Atlantic City as a site for the
Annual Meeting. It was suggested that the Committee expand its investigation of available sites.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
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NEW JERSEY MEDICINE
Nominations for
Emeritus Membership
(Reference Committee “B”)
The following nominations for election to emeritus membership at the 1990 Annual Meeting
have been received from the component societies. Conforming to the provisions of the Bylaws,
Chapter I — Membership Section 1 — Composition (d), all nominees have been members in good
standing of a component society and who by reason of age or infirmity have retired from the
active practice of medicine, or members of this Society who have been disabled by reason of
military service.
Bergen County
Vance T. Alexander, MD, Davidson, NC
(formerly Ridgewood); age 86
Joseph Catania, MD, Garfield; age 76
John T. Connell, MD, Englewood; age 64
Louis De Luca, MD, Ridgewood; age 76
Philip 0. Ettinger, MD, Leonia; age 54
Jerome Ferber, MD, Dumont; age 66
Robert S. Frankel, MD, Hackensack; age 68
John W. H. Glasser, MD, Fair Lawn; age 78
Cornelius F. Ivory, MD, Ridgewood; age 72
John P. Lauricella, MD, Englewood Cliffs; age 62
Vincenzo Lissandrello, MD, Teaneck; age 59
Rufus R. Little, MD, Ho-Ho-Kus; age 83
Howard W. Marraro, MD, Englewood; age 65
Joachim Oppenheimer, MD, Glen Rock; age 66
Frank J. Schaberg, MD, Hackensack; age 77
Jane V. Sokoll, MD, Oradell; age 66
Juin P. Tsai, MD, North Caldwell; age 70
June Winkler, MD, Hasbrouck Heights; age 62
Burlington County
Conrad M. Brahin, MD, Cherry Hill; age 66
Robert Heal, MD, Delanco; age 66
Thomas M. McMillan, III, MD, Medford; age 68
Gabriel Tatarian, MD, Willingboro; age 67
Camden County
August P. Ciell, MD, Cherry Hill; age 71
John M. Collier, MD, Haddonfield; age 66
Howard D. Easling, MD, Merchantville; age 66
Frank Orland, MD, Cherry Hill; age 70
Essex County
Robert H. Areson, MD, Savannah, GA
(formerly Wayne); age 75
Sylvia F. Becker, MD, Verona; age 69
Aaron Bernstein, MD, Short Hills; age 70
Robert V. Dorian, MD, Livingston; age 62
John F. Fitzgerald, MD, Bloomfield; age 63
Lydia S. Lashewycz, MD, Livingston; age 67
Michael T. Mahoney, MD, Roseland; age 66
Horace D. Marucci, MD, West Orange; age 73
Walter Nudelman, MD, Springfield; age 66
Robert K. Spiro, MD, Bloomfield; age 66
Paul H. Wannemacher, MD, West Orange; age 71
Francis A. Wood, MD, Montclair; age 63
Mary Wood, MD, Montclair; age 65
Hudson County
A. Albert Lepis, MD, Jersey City; age 84
Leon Reznikoff, MD, West Hartford, CT
(formerly Clifton); age 90
Moses M. Rothberg, MD, Palm Harbor, FL
(formerly West. New York); age 88
Gaspare F. Saitta, MD, Clifford Park; age 67
Albert V. Saradarian, MD, Rutherford; age 80
Diego Scambia, MD, Duck Key, FL
(formerly Union City); age 62
Evaristo L. Silva, MD,
Union City; age 67
Mercer County
Rafael Garces, MD, Princeton; age 59
Manuel Ortiz, MD, Lawrenceville; age 67
Middlesex County
Francis J. Godrey, MD, Naknmis, FL
(formerly Sayreville); age 66
Seymour Lifschutz, MD,
New Brunswick; age 68
Jasper L. Van Avery, MD,
New Brunswick; age 67
Monmouth County
Emanuel Abraham, MD, Deal Park; age 69
Forman T. Bailey, Jr, MD, Ocean Grove; age 70
Alexander C. Baret, MD, West Long Branch;
age 69
Peter R. Brady, MD, New Monmouth; age 67
George G. Bruzza, MD, Wall; age 72
Robert S. Ciampa, MD, Rome, Italy
(formerly Long Branch); age 69
Pascal L. Federici, MD, Long Branch; age 71
Mario F. Galassi, MD, Holmdel; age 66
Frank W. Gallo, MD, Little Silver; age 70
J. Berkeley Gordon, MD, Rumson; age 89
William A. Herbert, MD, Avon by the Sea; age 67
Charles F. Laycock, MD, Beverly Hills, FL
(formerly Long Branch); age 73
James G. Mazza, MD, Boynton Beach, FL
(formerly Long Branch); age 71
Allen M. Nicas, MD, Long Branch; age 69
James W. Parker, Jr, MD, Red Bank; age 71
Birute S. Preikstas, MD, Oakhurst; age 68
Carmen J. Scarpellino, MD, Monmouth Beach;
age 68
NEW JERSEY MEDICINE
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Morris County
Helen L. Miller, MD, Kinnelon; age 94
David R. Taylor, MD, Bernardsville; age 64
Eugene L. Watkins, MD, Morristown; age 72
Ocean County
Albert S. Basri, MD, Lakewood; age 71
James F. Dougherty, Jr, MD, Sea Girt; age 66
Jo Anne Overleese, MD, North Beach Haven;
age 67
Passaic County
Edward A. Abramo, MD, Wyckoff; age 67
John J. Bowe, MD, Ridgewood; age 68
Gordon W. Howe, MD, Fair Lawn; age 70
Joseph F. Kennedy, MD, Clifton; age 70
Somerset County
Harry Abramson, MD, Somerville; age 75
Albert M. Doswald, MD, Bridgewater; age 67
Joseph Pahlow, MD, Somerville; age 66
Henry A. Thomas, MD, Manville; age 75
Union County
Harry L. Baird, MD, Califon; age 66
Arnold J. Bajek, MD, Summit; age 67
Paul L. Chodosh, MD, Elizabeth; age 66
Edmond B. Cuce, MD, Murray Hill; age 70
Fermin E. Fernandez, MD, Elizabeth; age 64
Robert B. Francis, MD, Alpharetta, GA; age 68
Alfred L. Gandler, MD, Plainfield; age 65
Eugene R. Kertis, MD, Westfield; age 67
William J. Pflum, MD, Rumson; age 66
Emil G. Piserchia, MD, Hillside; age 66
John A. Sarno, MD, Belleville; age 70
Gloria O. Schrager, MD, Westfield; age 66
Robert C. Specht, MD, Summit; age 67
Warren County
James H. Spillane, MD, Phillipsburg; age 63
The Reference Committee recommended that the nominations be approved.
HOUSE ACTION: Adopted. The nominations were approved.
Supplemental Report #1
Nominations for
Emeritus Membership
(Reference Committee “B”)
Additional nominations for election to emeritus membership have been received:
Burlington County Union County
James Q. Atkinson, MD, Vincentown; age 72 Evalina D. LiSooey, MD, Mountainside; age 68
Hudson County
Maceo M. Howard, MD, Short Hills; age 67
Alfred J. Swyer, MD, West New York; age 71
Warren County
Volmar A. Mereschak, MD, Phillipsburg; age 68
The Reference Committee recommended that the nominations be approved.
HOUSE ACTION: Adopted. The nominations were approved.
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NEW JERSEY MEDICINE
Supplemental Report #2
Nomination for
Emeritus Membership
(Reference Committee “B”)
An additional nomination for election to emeritus membership has been received:
Union County
Louis J. Belle, MD, Elizabeth; age 69
The Reference Committee recommended that the nomination be approved.
HOUSE ACTION: Adopted. The nomination was approved.
Supplemental Report # 3
Nominations for
Emeritus Membership
(Reference Committee “B”)
The following additional nominations for election to emeritus membership have been re-
ceived:
Essex County Hudson County
Margaret M. Fitzpatrick, MD, Cliffside Park; Chester R. Rydwin, MD, Jersey City; age 70
age 67 Hector R. Wiltz, MD, North Bergen; age 64
Jose M. Vilanova, MD, Toms River; age 65
The Reference Committee recommended that the nominations be approved.
HOUSE ACTION: Adopted. The nominations were approved.
NEW JERSEY MEDICINE
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Resolution #1
fl
Introduced by:
Subject:
Referred to:
Union County Medical Society
HIV Infection as a Communicable Disease
Reference Committee “B”
Resolved, that the policy of the Medical Society of New Jersey state that human im-
munodeficiency virus infection be considered as any other reportable communicable disease, and
patients be treated accordingly.
The Reference Committee recommended that Resolution #1 be amended by the addition
of the words in italics.
HOUSE ACTION: Adopted. Resolution #1 was adopted as amended by the Reference
Committee.
Resolution #4
Introduced by: Essex County Medical Society
Subject: Regulation of Office Laboratories
Referred to: Reference Committee “B”
Whereas, the New Jersey State Department of Health is investigating and considering
regulating the policies and procedures for laboratories that perform nondiagnostic screening
laboratory assays, including cholesterol, hematocrit, erythrocyte protoporphyrin, and pregnancy
tests; and
Whereas, such screening tests presently do not fall under the clinical regulations of the New
Jersey Clinical Laboratory Improvement Act; and
Whereas, many physicians are interested in being laboratory directors for work performed
on their own patients; and
Whereas, physicians should have as many low-cost tests as possible so that higher medical
costs are not passed on to patients; now therefore be it
Resolved, that the Medical Society of New Jersey petition the New Jersey State Department
of Health to allow a physician the option to be his own laboratory-director; and be it further-
Resolved, that a physician be permitted to have as many tests as possible placed on the-
unregulated list in order to have many tests available to patients-for their convenience and low-
cost .
Resolved, that the Medical Society of New Jersey petition the New Jersey Department of
Health to promulgate such guidelines as have been proposed and acted upon by other states
which allow treating physicians the option to be their own laboratory director, and to perform
appropriate laboratory tests; and be it further
Resolved that exemptions be sought to allow a physician to perform, in his own laboratory,
an appropriate number of laboratory tests, subject to proper safeguards and standards on a
specialty specific basis, for the convenience and cost savings to the patient.
The Reference Committee recommended that a substitute resolution for Resolutions #4 and
#28E be adopted.
HOUSE ACTION: Adopted. The Substitute Resolution was adopted.
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NEW JERSEY MEDICINE
Resolution #5
Introduced by:
Subject:
Referred to:
Essex County Medical Society
Realistic Child and Scholastic Athletes’ Benefits
Reference Committee “B”
Whereas, Florida, Maine, Minnesota, and Washington have laws to provide children and
scholastic athletes with realistic health insurance; and
Whereas, children and scholastic athletes do not have lobbies, as do other groups with
insurance problems, and need the Medical Society of New Jersey as an advocate; and
Whereas, even most school and athletic insurance policies no longer provide uniform benefits
of value in all school injuries; now therefore be it
Resolved, that the Medical Society of New Jersey petition the New Jersey State Department
of Insurance to investigate realistic health insurance for children and scholastic athletes, as well
as realistic school and athletic insurance benefits to cover student injuries; and be it further
Resolved, that the Medical Society of New Jersey advise the New Jersey State Department
of Insurance that it stands ready to form a committee to advise the state of the problem and
to suggest possible solutions.
The Reference Committee, while recognizing the positive intent of the Resolution, felt that
further study is necessary for effective implementation of its objectives.
The Reference Committee recommended that Resolution § 5 be referred to the Board of
Trustees for appropriate action.
HOUSE ACTION: Adopted. Resolution #5 was referred to the Board of Trustees for
appropriate action.
NEW JERSEY MEDICINE
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Resolution #27E
Introduced by: Robert H. Stackpole, MD, Delegate, Union County
Subject: HIV Testing for Hospital Admissions
Referred to: Reference Committee “B”
Whereas, the Centers for Disease Control reported on May 2, 1990, an incidence of 25 percent
HIV positive tests at one hospital in the New Jersey-New York area; and
Whereas, New Jersey has one of the highest rates of HIV positivity in the nation; and
Whereas, knowledge of patients’ HIV status is important in further diagnosis and treatment
of those patients; and
Whereas, knowledge of HIV positivity is helpful in protecting hospital personnel; now
therefore be it
Resolved, that the Medical Society of New Jersey request that the New Jersey Department
of Health require that all hospital admissions have HIV testing where medically indicated.
Resolved, that the Medical Society of New Jersey request the New Jersey Department of
Health to treat HIV testing like any other blood test and eliminate the need for a special consent.
The Reference Committee recommended that the Resolution be amended by adding the
words “where medically indicated” to the first resolved.
Doctor Richard H. McShane, delegate from Essex County, suggested the addition of a second
resolved.
The Reference Committee recommended that Resolution #27E be adopted as amended by
the Reference Committee.
HOUSE ACTION: Not adopted. Resolution #27E and suggested amendments were
referred to the Board of Trustees.
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NEW JERSEY MEDICINE
I,
Resolution #28E
Introduced by:
Subject:
Referred to:
Henriette E. Abel, MD, Delegate,
The Dermatological Society of New Jersey
Increased Exemptions from CLIA 88 on a Specialty Specific Basis
Reference Committee “B”
Whereas, the Health Care Financing Administration is proposing to implement CLIA 88
in the immediate future; and
Whereas, the proposed list of exempt laboratory procedures is very limited; and
Whereas, patients will be denied ready access to and rapid interpretation of ordinary,
common laboratory tests, that are routinely performed in physicians’ offices, for which these
physicians are specifically trained; and
Whereas, denial of these common in-office laboratory procedures will result in greatly
increased expense and tremendous inconvenience, which is to the detriment of patients’ health;
and
Whereas, specialists are well-trained in doing certain laboratory tests in their own fields,
such as dermatologists performing KOH tests, fungal cultures, Tzanek smears, and dark field
examinations, urine cultures by urologists, hanging drop by gynecologists, and blood sugars by
internists; now therefore be it
Resolved, that the Medical Society of New Jersey protest to the Health Care Financing
Administration that the new CLIA 88 regulations should allow a moderate number of exemptions
-on a specialty specific basis for-tests that normally are performed in- a- physicians office.
Resolved, that the Medical Society of New Jersey petition the New Jersey Department of
Health to promulgate such guidelines as have been proposed and acted upon by other states
which allow treating physicians the option to be their own laboratory director, and to perform
appropriate laboratory tests; and be it further
Resolved, that exemptions be sought to allow a physician to perform, in his own laboratory,
an appropriate number of laboratory tests, subject to proper safeguards and standards on a
specialty specific basis, for the convenience and cost savings to the patient.
The Reference Committee recommended that a substitute resolution for Resolutions #4 and
#28E be adopted.
HOUSE ACTION: Adopted. The Substitute Resolution was adopted.
NEW JERSEY MEDICINE
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Council on Medical Services
RICHARD H. SHARRETT, MD, CHAIRMAN
(Reference Committee “C”)
The Council reviewed the Board of Trustees’ referral of the reimbursement and completion
of the Social Security Disability Determination form. The Council adopted an abbreviated form
that would require less time and effort for completion and has sent this recommendation to the
Board of Trustees for their consideration.
The Council also reviewed the process regarding PRO preauthorization. The Council rec-
ommended to the Board of Trustees that the Medical Society of New Jersey recognize that
Pennsylvania Blue Shield is inappropriately denying or postponing payments for prostatectomy
in cases of carcinoma of the prostate where precertification is not required.
The Council also has asked the Board to request Pennsylvania Blue Shield to review its
payment procedures in all cases where precertification numbers are not required, as well as other
such procedures having no number due to emergency circumstances.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
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NEW JERSEY MEDICINE
Resolution #3
Introduced by:
Subject:
Referred to:
Essex County Medical Society
Third-Party Reviewers
Reference Committee “C”
Whereas, the third-party reviewer “hassle factor” increasingly is becoming difficult to deal
with for physicians; and
Whereas, insurance companies are using out-of-state reviewers for precertification and
concurrent review of hospitalized patients via the telephone; and
Whereas, the State Board of Medical Examiners has taken the position that reviewing charts
is the practice of medicine; and
Whereas, some states, i.e. Kansas, have enacted laws requiring physician reviewers to be
licensed in their particular state; now therefore be it
Resolved, that the Medical Society of New Jersey petition the State Board of Medical
Examiners to rule-that all review in the state of New Jersey be done by New Jersey licensed
physicians,
Resolved, that the Medical Society of New Jersey petition the State Board of Medical
Examiners and the New Jersey Department of Insurance to rule that all quality and utilization
review of medical charts of patients treated in the state of New Jersey must be done by New
Jersey licensed physicians.
The Reference Committee recommended that Resolution #3 be amended to read as follows:
Resolved, that MSNJ petition the State Board of Medical Examiners to rule that all
quality and utilization review of medical charts in the state of New Jersey must be done by
New Jersey licensed physicians with the appropriate specialty designation.
The Reference Committee recommended that Resolution § 3 be adopted as amended.
HOUSE ACTION: Not adopted. Resolution #3 was adopted as amended by the House
of Delegates.
NEW JERSEY MEDICINE
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Resolution #7
Introduced by: Bergen County Medical Society
Subject: Objection to HCFA Administrative Policies
Referred to: Reference Committee “C”
Whereas, the administrative policy of HCFA has become so onerous; and
Whereas, we have found its procedures inconsistent, defective, deficient, and contradictory;
and
Whereas, HCFA’s actions are inimical to patients’ best interests and challenge the integrity
of physicians; and
Whereas, the profession is overburdened by administrative regulations; now therefore be
it
Resolved, that the Medical Society of New Jersey seek legal redress from the Health Care
Financing Administration and its intermediaries.
The Reference Committee felt that Resolution #7 was too vague and since it dealt with a
federal agency, it should be addressed by the AMA.
The Reference Committee recommended that Resolution #7 be rejected.
HOUSE ACTION: Adopted. Resolution #7 was rejected.
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NEW JERSEY MEDICINE
Resolution #8
Introduced by:
Subject:
Referred to:
Bergen County Medical Society
Objection to Physician Requirement To Fill Out Claims
for Medicare Beneficiaries
Reference Committee “C”
Whereas, the Omnibus Budget Reconciliation Act (OBRA) of 1989 states that, as of Septem-
ber 1, 1990, all physicians will be required to complete and submit to Medicare all claims for
Medicare beneficiaries; and
Whereas, this requirement will be a cumbersome, expensive, and unnecessary chore for most
physicians’ offices; and
Whereas, this will require additional personnel and extra work without reimbursement for
the said items; now therefore be it
Resolved, that the Medical Society of New Jersey urge the American Medical Association
to take action either to stop or delay implementation of the Omnibus Budget Reconciliation
Act (OBRA) of 1989 requirement that physicians complete claims for Medicare beneficiaries.
Because of their similar intent, the Reference Committee combined consideration of Reso-
lutions #8 and #11. The Reference Committee felt that Resolution #11 more clearly defined the
issues.
The Reference Committee recommended that Resolution #8 be rejected.
HOUSE ACTION: Adopted. Resolution #8 was rejected.
Resolution #9
Introduced by: Bergen County Medical Society
Subject: Objection to Malpractice Surcharge
Referred to: Reference Committee “C”
Whereas, the New Jersey Medical Malpractice Reinsurance Association deficit is solely the
result of improper and irresponsible policies of the New Jersey State Department of Insurance;
and
Whereas, the surcharge is an unjust and arbitrary taxation of the medical profession; now
therefore be it
Resolved, that the Medical Society of New Jersey continue to use every possible means
to overturn the malpractice surcharge regulation of the New Jersey Department of Insurance
and use legal counsel to pursue to the highest court.
The Reference Committee recommended that Resolution #9 be adopted.
HOUSE ACTION: Adopted. Resolution #9 was adopted.
HEW JERSEY MEDICINE
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Resolution #10
Introduced by:
Subject:
Referred to:
Bergen County Medical Society
Limited Endorsement of Suppliers of Membership Services
Reference Committee “C”
Whereas, many members have been dissatisfied with the position of the Medical Society
of New Jersey in recommending only one insurance company and/or legal firm for membership
services; now therefore be it
Resolved, that the Medical Society of New Jersey Board of Trustees, through the Committee
on Membership Services, offer three alternatives to all Society-endorsed programs, with the
exception of the programs from the Medical Inter-Insurance Exchange of New Jersey.
There was extensive discussion on Resolution #10. Statements were made that exclusivity
allows the suppliers of services to offer a better rate and makes for better accountability. The
Reference Committee felt that physicians should weigh all options available to them and act
on the basis of enlightened self-interest.
The Reference Committee recommended that Resolution #10 be rejected.
HOUSE ACTION: Adopted. Resolution #10 was rejected.
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NEW JERSEY MEDICINE
Resolution #11
Introduced by:
Subject:
Referred to:
Union County Medical Society
Medicare Billing
Reference Committee “C”
Whereas, the 1989 Omnibus Budget Reconciliation Act (OBRA) requires that as of Septem-
ber 1, 1990, physicians must submit all health care claims for Medicare patients for whom they
do not accept assignment; and
Whereas, this process is a major intrusion into the long-established doctor-patient rela-
tionship; and
Whereas, this process would require a considerable increase in office personnel to accomplish
this procedure and answer inquiries — many of which would be due to errors by the Medicare
carriers; and
Whereas, this shift of paperwork from the Medicare intermediary and the patient to the
physician’s office would apparently be achieved without additional compensation to the phy-
sician; now therefore be it
Resolved, that the Medical Society of New Jersey petition the New Jersey congressional
delegation to help to rescind the provision of the 1989 Omnibus Reconciliation Act (OBRA)
requiring physicians to submit all claims for Medicare patients for whom they do not accept,
-assignments and be it further
Resolved, that the AMA be requested to take a position of strong opposition to this
provision; and be it further
Resolved, that the AMA petition Congress to change this provision.
Because of their similar intent, the Reference Committee combined consideration of Reso-
lutions # 8 and #11. The Reference Committee felt that Resolution #11 more clearly defined the
issues.
The Reference Committee recommended that the words “for whom they do not accept
assignment” in the first resolved of Resolution #11 be deleted.
The Reference Committee recommended that Resolution #11 be adopted as amended.
HOUSE ACTION: Adopted. Resolution #11 was adopted as amended by the Reference
Committee.
NEW JERSEY MEDICINE
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Resolution #12
Introduced by: Union County Medical Society
Subject: Prescriptions in Nursing Homes
Referred to: Reference Committee “C”
Whereas, nursing home facilities are strictly regulated by state and federal laws; and
Whereas, physicians are licensed to practice medicine in the state of New Jersey; and
Whereas, physicians are additionally credentialed to practice in hospitals and nursing
homes; and
Whereas, “interpretive guidelines for drug therapy in nursing home facilities” encroach upon
physicians and their ability to practice in a nursing home facility; now therefore be it
Resolved, that the prescribing of medications should be based on the best interests of a
particular patient as perceived by the attending physician; and be it further
Resolved, that the needs of the patient should be the sole determinant of the type of
medication prescribed, and not a bureaucratic cookbook of treatments; and be it further
Resolved, that the Medical Society of New Jersey convey this position these concerns to
the State Board of Medical Examiners, the New Jersey State Department of Health, and any
related agencies regulating or impacting on the regulating of nursing home facilities.
The Reference Committee recommended that. Resolution #12 be amended (amendments in
italics).
HOUSE ACTION: Adopted. Resolution #12 was adopted as amended by the Reference
Committee.
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NEW JERSEY MEDICINE
Resolution #17
Introduced by:
Subject:
Referred to:
Ocean County Medical Society
Frivolous Suits
Reference Committee “C”
Whereas, many malpractice suits are without merit and frivolous; and
Whereas, such suits that fail or are dropped, nevertheless harm the defendant and increase
the cost of malpractice insurance; and
Whereas, no mechanism exists to bring this situation to the attention of the public; now
therefore be it
Resolved, that physicians submit documentation of such frivolous cases to the Medical
Society of New Jersey; and be it further
Resolved, that if the Medical Society of New Jersey concurs, letters of opinion and admoni-
tion be sent to the plaintiff s attorney; the insurance carrier; and the New Jersey Bar Association.
Resolved, that the Medical Society of New Jersey request the Medical Inter-Insurance
Exchange of New Jersey to submit quarterly reports to MSNJ’s Board of Trustees with analyses
of those malpractice cases that have been dismissed without merit as well as those cases in which
the jury verdict was in favor of the physician defendant with recommendation as to whether
plaintiff s attorney may not have followed acceptable legal standards.
There was considerable discussion on Resolution #17. The Reference Committee felt that
the second resolved was not appropriate.
The Reference Committee recommended that the second resolved be deleted.
Doctor Frank J. Malta, delegate from Ocean County, suggested the addition of a third
resolved.
The Reference Committee recommended that Resolution #17 be adopted as amended.
HOUSE ACTION: Not adopted. Resolution #17 and suggested amendment (third re-
solved) were referred to the Board of Trustees.
NEW JERSEY MEDICINE
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Resolution #18
Introduced by:
Subject:
Referred to:
Ocean County Medical Society
Replacement of Medicare Carrier
Reference Committee “C”
Whereas, Pennsylvania Blue Shield has not provided physicians with comprehensive
documentation of its rationale for denial of payment for services; and
Whereas, physicians are unable to predict and to avoid denial of payment notices, at great
embarrassment to physician and patient; and
Whereas, Pennsylvania Blue Shield has been unremitting in the denial of payment for
surgical assistance, in spite of State Board of Medical Examiners and hospital regulations and
the needs of the safe performance of surgical procedures; and
Whereas, Pennsylvania Blue Shield generally has been inefficient as a Medicare carrier,
unnecessarily encumbering physicians with reams of documentation; now therefore be it
Resolved, that the Medical Society of New Jersey petition the Health Care Financing
Administration to replace Pennsylvania Blue Shield as the Medicare carrier for the state of New
Jersey.
The Reference Committee took cognizance of the heated discussion on Resolution #18.
The Reference Committee recommended that Resolution #18 be adopted.
HOUSE ACTION: Adopted. Resolution #18 was adopted.
Resolution #19
Introduced by:
Subject:
Referred to:
Ocean County Medical Society
Qualifications of Experts in Medical Malpractice Cases
Reference Committee “C”
Whereas, the credentials of medical experts are included in testimony given in malpractice
action; and
Whereas, there have been incidences of false testimony or testimony at odds with medical
knowledge by experts; and
Whereas, medical experts impact the outcome of malpractice actions; now therefore be it
Resolved, that the Medical Society of New Jersey establish guidelines to be used by the
courts for the credentialing of medical experts and behavior of medical experts; and be it further
Resolved, that an ad hoc committee be so constituted to advise the Board of Trustees;
and be it further
Resolved, that such recommendations be forwarded to appropriate legal organizations and
judiciary bodies in the state of New Jersey.
The Reference Committee recommended that Resolution #19 be adopted.
HOUSE ACTION: Not adopted. Resolution #19 was adopted as amended by the House
of Delegates (with the addition of the second resolved).
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NEW JERSEY MEDICINE
Resolution #20
Introduced by:
Subject:
Referred to:
Ocean County Medical Society
Formation of a Counter Litigation Society
Reference Committee “C”
Whereas, malpractice actions or potential actions have affected the manner in which medi-
cine is practiced today; and
Whereas, consequences of malpractice actions have dire effects upon practitioners; and
Whereas, malpractice actions may be initiated on the basis of poor medical outcome, hired
medical experts whose testimony is not supported by the facts or whose testimony is at odds
with medical knowledge, and/or the filing of a frivolous suit; and
Whereas, such actions have profound psychological and adverse effects on the reputations
of practitioners; now therefore be it
Resolved, that the Medical Society of New Jersey support the formation of an organization
whose purpose is to take appropriate action in all cases of alleged malpractice by its members
in which the allegations are not supported by subsequent legal action; such action is to be taken
against the plaintiff, the attorneys, and/or the medical experts.
In view of the previous action recommended on Resolution #17, the Reference Committee
did not support the adoption of Resolution #20.
The Reference Committee recommended that Resolution #20 be rejected.
HOUSE ACTION: Adopted. Resolution #20 was rejected.
JEW JERSEY MEDICINE
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Resolution #21
Introduced by: Ocean County Medical Society
Subject: Clarify Medicare Definition of Medically Unnecessary Services
Referred to: Reference Committee “C”
Whereas, Public Law 99-509 prohibits nonparticipating physicians from billing Medicare
patients for services determined by the carrier to have been medically unnecessary; and
Whereas, the Health Care Financing Administration, through the Secretary of the Depart-
ment of Health and Human Services, has failed to provide physicians with guidelines for
noncovered services or for services deemed medically unnecessary; and
Whereas, such noncovered services and medically unnecessary services provided in good
faith may have dire consequences to physicians providing medical care to Medicare recipients;
now therefore be it
Resolved, that the Medical Society of New Jersey, through its delegates to the American
Medical Association (AMA), seek to obtain, through amended legislation if necessary, that
guidelines be promulgated for Medicare recipients as to noncovered services as well as guidelines
as to what may not be considered as medically necessary; and be it further
Resolved, that established appeal processes be made known to Medicare recipients and
physicians in a timely fashion prior to the issuing of a preliminary consideration for denial as
well as the procedure to follow in a formal appeal; and be it further
Resolved, that such guidelines and appeal processes should be stated in language that easily
is understood.
The Reference Committee felt that MSNJ should continue with its present course of action
with respect to this issue.
The Reference Committee recommended that Resolution §21 be adopted.
HOUSE ACTION: Adopted. Resolution #21 was adopted.
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NEW JERSEY MEDICINE
Resolution #26E
Introduced by:
Subject:
Referred to:
Bergen County Medical Society
Medicare Physician Toll-Free Telephone Service
Reference Committee “C”
Whereas, the Health Care Financing Administration transferred the carrier functions from
the Prudential in New Jersey to Pennsylvania Blue Shield in Pennsylvania; and
Whereas, Pennsylvania Blue Shield and the Health Care Financing Administration has
provided a telephone toll-free service for physicians to facilitate answering inquiries about
Medicare Part B benefits, claims processing procedures, amounts of claim payments or reasons
for denial, and claim status; and
Whereas, each physician inquiry requires an extensive amount of telephone time for reso-
lution; and
Whereas, by discontinuing the telephone toll-free service, effective June 30, 1990, toll calls
to Pennsylvania are unfair and would place an additional financial burden on physicians; now
therefore be it
Resolved, that the Medical Society of New Jersey take action to urge Pennyslvania Blue
Shield and the Health Care Financing Administration to continue the toll-free service to the
physicians in New Jersey; and be it further
Resolved, that the Medical Society of New Jersey take action to urge Pennsylvania Blue
Shield and the Health Care Financing Administration to provide telephone numbers in either
area codes (201) and/or (609) for New Jersey physicians’ use in communicating with the Medicare
center.
The Reference Committee recommended that Resolution #26E be adopted.
HOUSE ACTION: Not adopted. Resolution #26E was adopted as amended by the House
of Delegates (with the addition of the second resolved).
NEW JERSEY MEDICINE
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Council on Public Relations
JOSEPH N. MICALE, MD, CHAIRMAN
(Reference Committee “D”)
The Council on Public Relations studied a number of projects in conjunction with the
suggestions offered by the House of Delegates, the Board of Trustees, the general membership,
and individual contributions made by members of the Council on Public Relations, as well as
legislative public relations campaign contributions from Katz Martin & Company.
1. Resolution and Recommendations — 1989. From the House of Delegates, Board of
Trustees, Council on Public Relations, membership, and executive director of the Medical
Society of New Jersey.
A. A specific mandate from the House of Delegates was Resolution #5, a recommendation
that MSNJ sponsor television public service announcements and news releases to educate the
public on proper waste disposal habits.
B. The Council reviewed and discussed programming of MSNJ’s public relations activities
for the 1989 yearly schedule. The development and implementation of media releases followed
the Council’s review: Pollution Can Kill; Doctor’s Medicare Fees; Medicare, HMOs, DRGs —
Government Id-escribed Medicine Is Getting Harder and Harder To Swallow; The World Is in
Your Hands; Skyrocketing Medical Costs; and Professional Liability.
MSNJ’s public relations efforts are directed to present an acceptable image of New Jersey
physicians attempting to deliver quality health care to their patients under increasingly difficult
conditions, and to encourage the public to make their concerns known to their legislative
representatives.
2. Public Relations Activities — Continuing Projects.
A. Publication and distribution of the Membership Newsletter as part of NEW JERSEY
MEDICINE, the journal of the Medical Society of New Jersey.
B. Monthly public health/public relations releases in the media, primarily newspapers and
magazines ( Time/Newsweek ).
C. There were 30-second public service television releases on pollution control developed
from our media releases.
D. Preparation and distribution of special news releases and publicity as required in
furtherance of the Society’s interest and activities including: Annual Meeting, selected official
programs, and special activities.
E. The Golden Merit Award Ceremony at which MSNJ senior physicians who have held
the degree of doctor of medicine for 50 years receive formal recognition from their peers for
devotion to their profession and the patients they have faithfully served.
F. Support of orientation programs for new members by component societies.
G. Placement services in NEW JERSEY MEDICINE.
H. Participation in medical television programs of informational value to the public —
Channel 9-13 (cable) plus commercial stations in New York and Philadelphia using doctors from
our specialty societies as speakers, plus political action program support.
I. Newspapers. This year MSNJ published multiple releases on health topics such as:
Pollution Can Kill; Doctor’s Medicare Fees; Medicare, HMOs, DRGs — Government Prescribed
Medicine Is Getting Harder and Harder To Swallow; The World Is in Your Hands; Skyrocketing
Medical Costs; and Professional Liability.
J. Television. Public service announcements continue to be aired out of New York and
Philadelphia commercial stations and New Jersey Network Public Broadcasting television, using
15- to 30-second television tapes on Pollution Can Kill.
3. Special Programing.
A. The Council on Public Relations recommended three proposed releases on DRGs, health
care costs, and senior medical courtesy programs be developed and reviewed for use in doctors’
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NEW JERSEY MEDICINE
offices. County medical societies were solicited for their interest— Camden, Essex, Monmouth,
Ocean, and Passaic Counties responded.
B. Participation on Governor’s Committee on Child Abuse.
C. Support of Eye Health Screening Promotion.
D. Public relations support of legislative activities by Katz Martin & Company.
E. Development of annual public relations brochure for membership information.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
*JEW JERSEY MEDICINE
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n
ft
Council on Legislation
IRVING P. RATNER, MD, CHAIRMAN
(Reference Committee “D")
This report presents a summary of the ultimate status of legislative measures of the 203rd
Legislature. The Council’s operations, together with a cumulative report of MSNJ’s official
positions on current legislation, are reflected regularly in the official bulletins dispatched to state
legislative keymen and to component societies, and in items published in the Membership
Newsletter in NEW JERSEY MEDICINE, the journal of the Medical Society of New Jersey.
The Council on Legislation continues to invite an official representative from each specialty
society to all Council meetings. A notice announcing the date of each of the Council’s meetings
also is sent to all MSNJ official intermediaries with New Jersey specialty societies.
The Council urges that more representatives attend its meetings so it may have the benefit
of the timely thinking of specialty societies concerning proposed legislation affecting the specialty
fields.
The Council also invites the chairman or representatives of each council and standing
committee to attend the legislative meetings. Recent bylaw amendments make it possible for
one Auxiliary member, one resident member, and one student member appointed by the presi-
dent, to serve on the administrative councils and committees for a one-year term to be full voting
members of the representative council and committees.
There are special sections in NEW JERSEY MEDICINE dealing with legislative and
regulatory updates. The status of all active MSNJ legislative matters is detailed.
The following is a list of bills of the 1988 to 1989 Legislature that were reviewed after the
meeting of the 1989 House of Delegates:
SENATE/ASSEMBLY (Active)
S-722 — Codey — Mental Health Coverage. Requires health insurers (hospital service corporations) to
provide coverage for mental illnesses. Active Support.
S-723 — Codey — Mental Health Coverage. Requires health insurers (medical service corporations) to
provide coverage for mental illnesses. Active Support.
S-724 — Codey — Mental Health Coverage. Requires health insurers (commercial group health) to
provide coverage for mental illnesses. Active Support.
S-725 — Codey — Mental Health Coverage. Requires health insurers (commercial individual health)
to provide coverage for mental illnesses. Active Support.
S-726 — Codey — Mental Health Coverage. Requires health insurers (HMOs) to provide coverage for
mental illnesses. Active Support.
S-727 — Codey — Mental Health Coverage. Requires health insurers (health service corporations) to
provide coverage for mental illnesses. Active Support.
S-3440 — Codey — Generic Substitution/Prescription Blank Change. Changes prescription forms to
facilitate use of generic drugs. Active Opposition, filling out the new prescription format would require
more time for physicians; the probability of forgetting to write the required words to override generics
was greater when using a blank form and, therefore, the new format would not be in the best interest
of patients.
S-3494 — Zane — Unemployment Compensation and Disability Benefits. Exempts physicians who are
independent contractors from employment and disability taxes. Clarifies an ambiguity in the current law.
Active Support.
S-3549 — Lynch — Optometric Use of Drugs. Permits optometrists to use drugs for diagnostic and
treatment purposes. Active Opposition, optometrists are not medical doctors and, therefore, should not
be given the mandate, via legislation, to administer drugs. If the wrong medication is prescribed, what
appears to be a simple problem could develop into a destructive process of the eye in a very short period
of time. The bill is shortsighted in attempting to provide less expensive care to the general public to the
detriment of their health.
A-4259 — Naples — Medical Records. Would require that records be “furnished upon request to the
patient and/or his duly authorized representative immediately.” Active Opposition, this situation is
adequately covered under existing regulation and could not be implemented in the form stated in the bill.
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NEW JERSEY MEDICINE
SENATE/ASSEMBLY (Monitor)
S-734 — Codey — Financial Disclosure. Prohibits physician from referring patients for services in which
the physician or his immediate family hold a significant ownership interest unless the patient is advised,
in writing, and given the option of a prescription. Conditional Approval, pending disclosure is expanded
to all providers. (Law c.19, P.L. 1989.)
S-2939— Van Wagner— Emergency Services. Appropriates $1.5 million to the Department of Health
to be used for EMS training and equipment. Approved.
S-3104 — Lipman — AIDS. Makes AIDS or HIV sensitivity reportable to the Department of Health and
provides for confidentiality. Action Deferred, pending review of the Task Force on AIDS of the Assembly
amendments to S-3104. (Law c.303, P.L. 1989.)
S-3236 — Rice — AIDS. Requires that persons convicted for using controlled dangerous substances shall
be tested for AIDS and HIV sensitivity. Action Deferred, pending reconsideration of the Task Force on
AIDS concerning this legislation.
S-3261 — Bassano — Drug Testing Student Athletes. Requires school boards to establish random drug
testing programs for student athletes. Testing would be done at school board expense. Disapproved, the
issue of drug abuse in the school extends beyond the scope of the student athlete. This bill, therefore,
would send the wrong message and ignores the need to educate and test beyond the athlete population.
S-3320 — Ambrosio — Health Care Directives. Establishes procedures for the execution of advance
directives for health care. The advance directives involve designation of a health care representative and
a statement of personal wishes in the event of loss of decision-making capacity. Action Deferred, pending
review of the Senate committee amendments by the Committee on Biomedical Ethics.
S-3327 — Codey — Infection Control Education. Requires institutions that educate allied health pro-
fessionals to incorporate infection prevention and control as part of their program. No Action.
S-3346 — Codey — Laboratory Director’s Licensing. Adds “diagnostic laboratory immunology” to the
list of specialty licenses. No Action.
S-3389 — Paterniti — Health Needs Study ( same as A-2987). Requires the commissioner of health to
conduct a study of the health needs of low-income persons over the age of 60. Disapproved, this study
is unnecessary, there is a wealth of information on this topic available through federal and academic sources.
S-3429 — Ewing — Commissioner of Health (same as A-4142). Deletes the requirement of a medical
license to be commissioner of health. Conditional Approval, pending amendment of the bill to create
a position of physician general and also to include an MSNJ representative on the Health Care Adminis-
tration Board.
S-3433 — D’Amico — Medical Waste. Increases the categories of regulated medical waste to include —
wastes from surgery or autopsy that were in contact with infectious agents, including soiled dressings,
sponges, drapes, lavage tubes, drainage sets, underpads, and surgical gloves; laboratory wastes from
medical, pathological, pharmaceutical, or other research, commercial, or industrial laboratories that were
in contact with infectious agents, including slides and cover slips, disposable gloves, laboratory coats, and
aprons; dialysis wastes that were in contact with the blood of patients undergoing hemodialysis, including
contaminated equipment and supplies such as tubing, filters, disposable sheets, towels, gloves, aprons,
and laboratory coats; discarded medical equipment and parts that were in contact with infectious agents;
biological waste and discarded materials contaminated with blood, excretion, exudates or secretion from
human beings or animals who are isolated to protect others from communicable diseases. Disapproved,
w/ Active Opposition if the bill moves, until the current law is effectively implemented.
S-3463 — Contillo — HIV Testing for Certain Defendants. Mandates HIV testing when any criminal
commits an offense that results in a victim or third party exchanging body fluids or a needle stick if there
is probable cause to believe the defendant is an intravenous drug user. Action Deferred, pending further
information from the Task Force on AIDS with the following recommendation that the bill be amended
to read “that any person who is charged with a criminal offense that results in the victim or a third party
exchanging body fluids should be tested for HIV positivity.”
S-3479— Zimmer— Hospital Uncompensated Care Charges. Requires hospital to itemize un-
compensated care costs on patient bills. No Action.
S-3546— Feldman— Sexually Abused Children. Requires the commissioner of human services to
establish two regional treatment centers for sexually abused children. The regional centers would be
networked into community-based model programs and a research institute at one of the schools of higher
education. No Action.
S-3565— Ewing— HIV Testing of Newborns. Requires that all newborns be tested for HIV sensitivity.
Action Deferred, pending further information from the Task Force on AIDS with the following recommen-
dations: 1. consider HIV testing of mother; 2. consider the possibility of HIV testing of all prenatal patients;
and 3. consider false negative and false positive readings and what should be done in these instances.
A-955— Kern— Artificial Insemination. Statutorily regulates artificial insemination, requires certain
forms of consent, data gathering, and recordkeeping. No Action. The Council directed that correspondence
be addressed to the sponsor of the bill recommending that it be written in conformance with the American
Fertility Society Guidelines.
A-1456— Kline— Organ Transplants. Prohibits organ transplants unless the tissues are HIV negative.
Approved.
NEW JERSEY MEDICINE
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A-2938 — Ogden — Communicable Disease. Requires health care facilities to notify first aid, am-
bulance, or rescue squads that the patient they are transporting has a communicable disease when that
fact is known to the facility. Approved.
A-2987 — Lobiondo — Health Needs Study (same as S-3389). Requires the commissioner of health to
conduct a study of the health needs of low-income persons over the age of 60. Disapproved, this study
is unnecessary; there is a wealth of information on this topic available through federal and academic sources.
A-3804 — Littell — Ambulance, Fire, Rescue Squads. Prohibits the formation of local, regional, or
statewide EMS coordinating areas. Approved.
A-4224 — Girgenti — Anabolic Steroids. Makes it a crime to dispense steroids without a prescription
to minors; requires the commissioner of health to conduct studies to determine whether anabolic steroids
should become scheduled drugs. Conditional Approval, pending deletion of the words “to minors,” making
it a crime to dispense steroids without a prescription. Also, pending notification that anabolic steroids
will not be added to the controlled schedule II listing (Law c.335, P.L. 1989).
A-4226 — Bush — Fetal Alcohol Syndrome (FAS) ( same as S-3149). Requires retail establishments
(alcohol) to post warnings about alcohol consumption during pregnancy. Approved.
A-4255 — Palaia — Tanning Salons (same as S-1554). Requires the Department of Health to establish
safety standards for tanning facilities that shall be enforced through the local board of health. Approved.
A-4284 — Impreveduto — Chiropractic Board. Creates a separate Board of Chiropractic Examiners and
transfers all current rules to the new board. No Action.
A-4299 — Kline — HIV Testing (Newborns). Requires that all newborns be tested for HIV sensitivity
under Department of Health guidelines. Action Deferred, pending further information from the Task Force
on AIDS with the following recommendations: 1. consider HIV testing of mother; 2. consider the possibility
of HIV testing of all prenatal patients; and 3. consider false negative and false positive readings and what
should be done in these instances.
A-4321 — Cooper — HIB. Requires the Department of Health to distribute information to physicians
on HIB vaccine. No Action.
A-4382 — Karcher — Video Terminals in Workplace. An employer shall make available to an operator
an annual eye and vision examination that conforms to the recommended components of an eye and vision
examination established by the American Optometric Association, with consideration given to the specific
requirements of visual correction that may be needed by an operator. No Action.
A-4453 — Smith — HIV Positive Psychiatric Patients. Provides that patients who are in state psy-
chiatric facilities and are HIV positive are to be isolated in accordance with policies approved by the
commissioner of human services and the commissioner of health. Action Deferred, pending further
information from the Task Force on AIDS, the Council on Mental Health, and the New Jersey Psychiatric
Association.
A-4536 — Randall — Health Care Directives. Establishes procedures for the execution of advance
directives for health care. The advance directives involve designation of a health care representative and
a statement of personal wishes in the event of loss of decision-making capacity. Action Deferred, pending
further information from the Committee on Biomedical Ethics.
A-4560 — Franks — Motor Vehicle Drivers — Drug Testing. Requires the Division of Motor Vehicles
to establish a three-year random sample drug testing program for applicants for a driver’s license. Disap-
proved, the cost of this legislation would make implementation of the bill very difficult.
A-4576 — McEnroe — Graduate Medical Education. Adds the dean of the School of Graduate Medical
Education at Seton Hall to the Advisory Council on Graduate Medical Education. No Action.
A-4577 — Villapiano — Emergency Medical Transportation Services. Requires the Department of
Health to notify county health departments of all persons residing in the county that are HIV positive.
The county health department is to pass the list on to each EMS transport provider. A similar notice
by hospitals is to be given to EMS transport when an HIV positive patient is leaving that hospital by
EMS transport. Disapproved, unenforceable, unworkable legislation.
A-4683 — Zecker — HMO-Medicare. Requires HMOs that offer services to Medicare recipients to
provide supplemental coverage in accordance with the Federal Catastrophic Coverage Act. No Action.
A-4684 — Zecker — Medicare-Medical, Hospital, and Service Corporations. Same as A-4683 applies
to Blue Cross & Blue Shield. No Action.
A-4685 — Zecker — Medicare-Health Insurers. Same as A-4683 applies to health insurers. No Action.
Of the bills reported to the House from the First and Second Sessions of the 203rd Legis-
lature, the following were signed into law:
ACTIVE SUPPORT
S-2673 — Corporate Immunity. Provides that officers and directors are immune from suits by members
or shareholders when acting in good faith unless there is a material conflict of interest.
S-2936 — The Professional Medical Conduct Reform Act. This legislation will substantially change
the operation of the New Jersey State Board of Medical Examiners. The enactment of this law is a major
advance in securing due process and fundamental fairness for physicians.
S-3867 — Medical Waste Fees. Imposes limitations on annual fees the Department of Environmental
Protection may charge and collect from medical waste generators.
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NEW JERSEY MEDICINE
Under 50 lbs/yr $100
50-200 lbs/yr $300
Over 200-300 lbs/yr $500
Over 300-1,000 lbs/yr $1000
Over 1,000 lbs/yr $3500
The DEP must refund the difference between what it collected and what is due under the new rate
table. Refunds must be made by July 2, 1990.
ACTIVE OPPOSITION
S-784 — Allows psychologist to certify disability.
A-3269 — Provides that chiropractors’ services are included in the definition of medical services under
workers’ compensation. (Chiropractic services have been included under workers’ compensation allowances
for over 20 years.)
APPROVED
S-1980 — Provides that volunteer trustees of nonprofit corporations may be immunized from paying
damages to the corporation or its membership.
S-1984 — This bill deletes the requirement in the law that a completed organ donation option certificate
be attached to a death certificate in order for the death certificate to be deemed complete. This bill is
necessary in order to ensure the prompt handling of the deceased once a death certificate is prepared.
S-1995 — Provides that volunteers providing services to blood banks shall be immune from civil liability
unless they have acted in a willful, wanton, or grossly negligent fashion.
S-2343 — Creates a medical waste disposal system whereby needles, syringes, and blood products would
have to be disposed of by special permit. Physicians, as generators, would be required to register with
the DEP.
S-2907 — Extends hospice coverage to Medicaid.
S-3076 — Requires school boards to distribute Heimlich maneuver educational materials.
S-3315 — Expands substance abuse education to include anabolic steriods and further provides for
testing and referral for treatment.
A-546 — Provides that students in public colleges must produce a medical history of their immuniza-
tions for preventable diseases.
S-4329 — Allows eye bank technicians and other medical students to enucleate eyes.
DISAPPROVED
S-1554 — Requires the Department of Health to establish safety standards for tanning facilities that
shall be enforced through the local boards of health.
S- 1816 — Prohibits the distribution and sale of irradiated foods.
A-130 — Provides that a licensed ophthalmic dispenser may certify successful completion of the required
visual examination for an operator’s license.
A-1774— Creates a 24-member Governor’s Council on Alcoholism and Drug Abuse and merges the
existing Division of Alcoholism and the Division of Narcotic and Drug Abuse Control within the Depart ment
of Health into a new Division of Alcoholism and Drug Abuse Control. It would coordinate all programs
within the state and make program and funding recommendations to the governor and the Legislature.
The governor is to appoint an independent evaluator who would conduct a study and tile a report on the
efficacy of the Council four years after enactment of the legislation.
A- 1843— Details the rights of patients in acute-care hospitals.
At the close of the 1988-1989 Legislative year, all of the bills expired except those signed into law,
vetoed, or filed by the Governor.
1989 HOUSE OF DELEGATES
Resolution #4 — Tanning Salon Legislation
Resolved, that the Medical Society of New Jersey work with the New Jersey Department of Health,
the Dermatological Society of New Jersey, and other appropriate agencies to determine what safety
precautions are needed regarding tanning salons in New Jersey, and whether or not legislation similar to
California law is advisable.
The Council on Legislation advised that the appropriate correspondence has been forwarded to review
the hazards presented by tanning salons in New Jersey.
The Reference Committee recommended that the report be filed.
HOUSE ACTION: Adopted. The report was filed.
NEW JERSEY MEDICINE
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Supplemental Report #1
Legislation
IRVING P. RATNER, MD, CHAIRMAN
(Reference Committee “D”)
At 12 o’clock noon, Tuesday, January 9, 1990, the Senate and General Assembly met for
organization of the First Annual Session of the 204th New Jersey State Legislature. As the
Legislature presently is constituted, the Senate has a total of 40 members consisting of 17
Republicans and 23 Democrats. The Assembly has a total of 80 members consisting of 36
Republicans and 44 Democrats. By means of official legislative bulletins, the Society’s official
legislative positions on all current state legislation are regularly called to the attention of
legislators as well as component societies, cooperating agencies, county keymen, and county
society executive directors and executive secretaries.
The Society has adopted the following regular range of official positions concerning proposed
legislation:
Watch List: For all Approved/Disapproved legislation.
Active Support: All-out support for the measure.
Active Opposition: All-out opposition for the measure.
Note and File: For all No Action legislation.
Conditional Approval: To indicate that the approval of the Society is conditional, subject
to elimination of the unsatisfactory elements of the bill that are pointed out.
Action Deferred: Pending amendment that will have substantial impact on Active sup-
port/Active Opposition legislation.
The Council offers this Supplemental Report §1 covering items dealt with since the compila-
tion of its Annual Report.
SENATE/ASSEMBLY (Active)
S-642 — Ewing — Commissioner of Health. Deletes the requirement of a medical license to be com-
missioner of health. Active Opposition, because the health care needs of our population require that a
licensed physician serve in the position of commissioner of health. There are many qualified candidates.
It is not advisable to dilute the requirements at a time when the nation and New Jersey, in particular,
face a major public health crisis, caused by drug addiction, AIDS, and environmental diseases.
S-1025 — Feldman — Social Work. This bill would establish and license two categories of social workers
and would create a Board of Social Work Examiners in the Department of Law and Public Safety whose
powers and duties, among others, would be to administer the act, examine and license candidates for the
various categories of social work, and promulgate rules and regulations necessary for the effective enforce-
ment of the act. The two categories of licensed social work would be (D social work specialists, who would
be required to have a doctorate in social work or a master’s degree from an accredited school of social
work and (2) social workers who would need a baccalaureate degree from an accredited college or university
social work or social welfare program. The bill would “grandfather” in all persons currently in practice,
provided they have been in practice in one of the two licensed categories for two of the last five years
and apply to be licensed within 180 days from the effective date of this act. Active Opposition, because
there has been no demonstrative need for licensure of this occupation as a separate and independent
profession.
S-1208 — Ambrosio — Declaration of Death. Sets forth the criteria to be recognized for a declaration
of death. Neurological criteria may not be used if they violate the personal religious beliefs or moral
convictions of the individual. Active Opposition, pending amendment removing the religious exemption
section of the bill.
S-1230 — Codey — Certificate of Need. Amends the certificate of need law to include physicians when-
ever a health service has been regionalized by regulation of the Department of Health. Regulations would
terminate within three years, at which time the commissioner could readopt the regulation. Active Opposi-
tion, there is no evidence the certificate of need concept is a valid regulatory system. It has proved to
be ineffective in containing costs; it has stifled initiative; its expansion to intrude on the private practice
of medicine is not warranted. Nationally, at least 11 states have repealed certificate of need legislation
and a number of federal agencies (including the Department of Health and Human Services and the Federal
Trade Commission) have called for its repeal.
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NEW JERSEY MEDICINE
S-1272 — Codey — Generic Substitution/Prescription Blank Change. Changes prescription forms to
facilitate use of generic drugs. Active Opposition, generic substitution is a questionable concept that must
not be advanced without safeguards and testing. Generic drugs have not been tested through FDA approved
clinical trials. At this time, the FDA is reviewing the generic issue. Liberalization of the generic law is
not indicated at this time.
S-1556 — Cardinale — Certificate of Need. Exempts the private practice of medicine from the
certificate of need law. Active Support.
S-1587 — Cardinale — Determination of Death. Establishes criteria and determination of death.
Creates a religious belief exemption regarding neurological factors. Active Opposition, pending amendment
removing the religious exemption section from the bill.
S-1864 — Dumont — Statute of Limitations. Provides for a three-year statute of limitations, except
for fraud, intentional concealment, or nontherapeutic or diagnostic purpose. Minors would have until age
11 on any injury prior to age 8. Active Support.
S-1975 — Orechio — Medicare Assignment. Requires health care licensees to accept Medicare de-
termination of their fees. Active Opposition, participation in any health plan is not a valid licensure
criteria, there is no evidence that a draconian measure of this nature is necessary since over 70 percent
of the physicians accept assignment in a given instance. The bill violates the New Jersey and U.S.
Constitution.
S-2016 — Contillo — National Health Care. Provides for a nonbinding referendum concerning the
enactment of a national health plan. Active Opposition, the bill presents a utopian approach and does
not consider the negative impact of failing to balance cost and quality factors. It is misrepresentation in
the purest form.
S-2051 — Codey — Dispensing of Drugs by Physicians. Prohibits physicians from dispensing more
than a 72-hour supply of drugs unless they are dispensed free of charge. Active Opposition, limits physician
ability to treat patient properly.
S-2100 — Lipman— Nursing Practice. Authorizes nurses to practice medicine and to prescribe drugs
and devices. Active Opposition, nurses are not qualified to make a medical diagnosis nor to prescribe
therapeutic medications.
S-2224 — Dalton — Medical Expenses in Auto Accidents. Requires health providers to directly bill
auto carriers when there is applicable PIP coverage. Active Opposition, this would make physicians and
patients captives of insurance companies and will lead to limited access for patients.
S-2225 — Dalton — Medical Expenses in Workers’ Compensation. Requires health providers to direct-
ly bill the employer or the compensation carrier whenever workers’ compensation insurance is applicable.
Active Opposition, this would make physicians and patients captives of insurance companies and will
lead to limited access for patients.
S-2295 — Ambrosio — No-Fault. Imposes a fee schedule at the 75 percentile; bans balance billing;
places an annual charge of $100 upon the licensee to practice medicine. LAW c.8 P.L. 1990.
S-2329 — Lipman — HIV Reporting. Amends recently adopted law and removes HIV sensitivity as a
reportable matter. Active Opposition, reporting of HIV sensitivity and contact tracing are essential to
the control of the AIDS epidemic. Additionally, the benefits of prompt treatment of HIV sensitive patients
would be frustrated.
SCR-84 — Zane — Regulation. Provides constitutional amendment that the legislature by majority vote
may override any rule or regulation. Active Support. (Doctor Weiss voted in the negative and is so
recorded.)
A-l—Doria— No-Fault. Revises no-fault. Provides for a $100 per year tax on medical licenses to help
offset the JUA deficit, provides for a medical fee schedule at the 75th percentile and a ban on balance
billing. LAW c.8 P.L. 1990.
A-234— Naples— Health Care Services. Bars actions to enforce the payment of bills for health care
services for 60 days under certain circumstances. Active Support. (Drs. Rosen and D’Ascoli voted in the
negative and are so recorded.)
A-264— Naples— Medical Records. Would require that records be “furnished upon request to the
patient and/or his duly authorized representative immediately.” Active Opposition, this situation is
adequately covered under existing regulation and could not be implemented in the form stated in the bill
without total disruption of hospital and medical services.
A-325— Deverin— Occupational Therapy. Creates a new class of licensed practitioners who would
function independently and would be permitted to perform such services as the design, fabrication, and
application of splints, sensorimotor activities, the use of specifically designed crafts, guidance in the
selection and use of adaptive equipment, therapeutic activities to enhance functional performance; prevoca-
tional evaluation and training, and consultation concerning the adoption of physical environments for the
handicapped. The State Board of Medical Examiners will exercise jurisdiction. Active Opposition, there
is no demonstrated public health need to create a licensed professional in occupational therapy. Currently,
physical therapists and nurses are meeting the needs of this legislation.
A-337— Deverin— Medicaid. Broadens the scope of Medicaid eligibility. Action Deferred, pending
further information from MSNJ’s Committee on Medicaid.
A-346— Deverin— Respiratory Therapists. Creates a Board to license and regulate respiratory thera-
pists. Services are to be provided under the direction or supervision of a physician. Active Opposition,
NEW JERSEY MEDICINE
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there is no need to separately register and license these therapists since they are functioning well under
existing laws.
A-366 — Colburn — Corrective Lenses. Prohibits the mail order sale of prescription lenses. Active
Support.
A-743 — Roberts — Optometric Use of Drugs. Permits optometrists to use and prescribe drugs. Active
Opposition, optometrists are not medical doctors and, therefore, should not be given the mandate, via
legislation, to prescribe and administer drugs. If the wrong medication is prescribed, what appears to be
a simple problem could develop into destructive process of the eye in a very short period of time. The
bill is shortsighted in attempting to expand licensure by legislation rather than education and competence.
A- 1540 — Girgenti — Structured Payments. Provides for structured settlements when future damages
exceed $150,000. Active Support.
A-1645 — Shusted — Dialysis Technicians. Creates a system for training and certifying dialysis tech-
nicians. Active Support.
A-1653 — Shusted — Structured Payments. Provides for structured payments in civil actions against
health care providers when future damages exceed $250,000. An annuity must be offered to guarantee the
future payments. Active Support.
A-1853 — Doria — HMO. Ensures HMO enrollees of a form of coverage when using non-HMO providers.
Active Support.
A-1893 — Moran — Medicare Fee Complaints. Establishes a public blacklist to be compiled by the
Division of Aging on those physicians whose fees exceed Medicare allowances. Active Opposition, Medicare
allowances are about 60 percent of usual fees. Ongoing congressional budget cuts will lower them further.
The compiling of a list will mislead patients from realizing that doctors are being paid less than they bill.
This type of misinformation should be avoided.
A-1970 — Kelly — Prescription of Drugs by Nurses. Allows nurses who practice in collaboration with
physicians to prescribe medications in accordance with protocols submitted to and approved by the State
Board of Nursing. Active Opposition, nurses are not qualified to make medical diagnosis nor to prescribe
therapeutic medications.
A-2019 — Ogden — Mental Health Benefits. Requires health insurers and HMOs to require specified
amounts of mental health benefits as mandated coverage. Active Support.
A-2020 — Ogden — Mental Health Benefits. Same as A-2019 except it applies to HMOs. Active
Support.
A-2021 — Ogden — Mental Health Benefits. Same as A-2019 except it applies to Blue Cross. Active
Support.
A-2022 — Ogden — Mental Health Benefits. Same as A-2019 except it applies to individual commercial
insurance. Active Support.
A-2023 — Ogden — Mental Health Benefits. Same as A-2019 except it applies to medical service
corporations. Active Support.
A-2024 — Ogden — Mental Health Benefits. Same as A-2019 except it applies to Blue Shield. Active
Support.
SENATE/ASSEMBLY (Monitor)
S-23 — Russo — Handguns. Prohibits the sale, importation, or possession of handguns with the excep-
tion of antiques. No Action. (Doctor Rosen voted in the negative and is so recorded).
S-61 — Zimmer — Emergency Services. Permits paramedics or registered nurses to ride with an EMT-
I unit and perform advanced life-support services. Approved.
S- 119 — Zimmer — Hospital Uncompensated Care Charges. Requires hospitals to itemize un-
compensated care costs on patient bills. Approved.
S-184 — Graves — Licensure Suspension. Suspends professional, occupational, and business licenses
upon conviction for a drug offense. Approved.
S-215 — Paterniti — Osteoporosis. Establishes a commission (15 members) to compile and analyze data
on osteoporosis, develop educational programs, and assist local health agencies in public education. Disap-
proved, osteoporosis is a well known, researched, and publicized condition. There is no need to create
a special legislative commission to conduct studies when scientific literature is readily available.
S-240 — Paterniti — Health Needs Study. Requires the commissioner of health to conduct a study of
the health needs of low-income persons over the age of 60. Disapproved, this study is unnecessary; there
is a large volume of information on this topic available through federal and academic sources.
S-286 — Lynch — Political Contributions. Amends the New Jersey election contribution laws. Limits
PAC contributions per candidate per election year. Also caps PACs at $100,000 per calendar year. No
Action.
S-317 — Rand — Burn Registry and Reporting. Requires physicians treating a person with burns over
5 percent of his body to report the same to state or local police. Establishes a central burn registry in
the Department of Community Affairs. No Action.
S-363 — Van Wagner — Wrongful Death. Expands recoverable damages in wrongful death actions to
include emotional and social factors along with mental anguish. Disapproved, Supreme Court decisions
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in New Jersey have established a reasonable and workable format awarding damages in wrongful death
actions. This bill would create an unwarranted expansion and escalate the cost of liability insurance without
benefit to the public.
S-371— VanWagner—Home Health Care. This bill establishes an 18-month Home Health and Com-
munity Care Demonstration Program in the Department of Human Services. This program is designed
to provide for the delivery of community-based home health care services by local Home Health and
Community Care Demonstration Centers to functionally impaired persons who are at least 65 years of
age or older or who are disabled pursuant to the Social Security Act. Action Deferred, pending further
information from MSNJ’s Committee on Senior Citizens.
S-J85 \ an\\ agner — Immunity. Requires physicians and others to report patients who have made
defined threats against third parties to the local police. Grants civil immunity to the reporting practitioner.
Approved.
S-393 — VanWagner — HMOs. Provides for the licensing and regulation of HMOs through the Depart-
ment of Insurance and transfers current authority from the Department of Health to the Department of
Insurance. Also provides for greater financial oversight. No Action.
S-400 Brown Ombudsman for Children. Creates an office of ombudsman to monitor services
rendered to children through the Department of Human Services. No Action.
S-404 Brown — DYFS Study Commission. Establishes a 15-member commission to study and report
on the operation of the Division of Youth and Family Services. Conditional Approval, pending amendment
adding a physician to the commission.
S-434 — DiFrancesco — Abuse of Elderly, Disabled, or Incapacitated Persons. Requires every person
who has reasonable cause to believe an elderly or disabled person is the victim of abuse or exploitation
to report that information to the commissioner of human services or his designee.
Approved.
S-584 — Ewing — Regulated Professions. Creates a review commission in the Division of Consumer
Affairs (five public members and four legislators). The commission would study and evaluate proposed
legislation regarding regulated professions and occupations. No Action.
S-608 — Ewing — Civil Immunity. Amends the Good Samaritan Act to extend immunity to those
responding to emergencies regardless of their lack of volunteer status. Disapproved, the concept of the
Good Samaritan Act would be destroyed by this proposal which is illogical.
S-611 — Ewing — AIDS. Requires physicians and hospitals to report patients with AIDS to the local
board of health within 24 hours of diagnosis ( and does not require reports on patients HIV positive).
Disapproved, impractical and unnecessary, since AIDS is reportable to the Department of Health.
S-612 — Ewing — Tattoo Parlors. Authorizes the Public Health Council to regulate sanitary conditions
in tattoo parlors. Approved.
S-613 — Ewing — AIDS. Requires persons being tested for venereal disease to also submit to testing
for AIDS; requires applicants for marriage licenses to be tested for AIDS. Approved.
S-615 — Ewing — AIDS (Prison System). Requires inmates in correctional institutions to be tested
for AIDS. Approved.
S-624 — Ewing — Prisoners/AIDS-HIV Sensitivity. Provides that all prisoners shall be tested for
sensitivity to HIV. Approved.
S-638 — Ewing — Fetal Alcohol Syndrome (FAS). Requires retail establishments (alcohol) to post
warnings about alcohol consumption during pregnancy. Approved.
S-644 — Ewing — HIV Testing of NewTborns. Requires that all newborns be tested for HIV sensitivity.
Action Deferred, pending further information from the New Jersey Chapter, American Academy of
Pediatrics.
S-648 — Ewing — Drunk Driving. Reduces drunken driving measurement from 0.10 to 0.08. No Action.
S-670 — Costa — Nursing Homes. Requires skilled nursing homes or intermediate care facilities to have
at least one registered nurse on duty 24 hours a day. Approved.
S-745 — Bubba — Drug Testing. Requires drug testing for scholastic athletes as part of the annual
physical examination. Disapproved, if tests are valid for school students, they should be applied to all
students, not just athletes.
S-756 — Bubba — Anabolic Steroids. Prohibits the nonprescribed use of anabolic steroids by college
athletes. Approved.
S-845 — Rice — Hospital Care for Indigents. Permits certain municipalities to require indigent patients
to go to the least expensive hospital. Disapproved, because this legislation would unnecessarily restrict
the choice of patients and doctors, produce dangerous delays, and conflict with current statutes.
S-916 — Cowan — Council on Disability. Establishes a council on disabilities consisting of 50 persons.
The council is to function as the primary planning and advisory body in state government on the interests
and needs of those with disabilities. A subcouncil on developmental disabilities with 20 members is created
within the overall council. Disapproved, the structure and function of this council and the process outlined
is unwieldy and counter-productive.
S-944 — Cowan — Licensing Board Immunity. Expands immunity from antitrust suits to licensing
boards to include their actions regarding admittance to a profession, suspension, and revocation of licenses.
Approved.
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S-969— Cowan — Health Insurance for the Unemployed. Establishes a plan designed to provide
health insurance to unemployed New Jersey residents who are unable to obtain other group health insurance
coverage. No Action.
S-1003— Feldman— Privileged Communication. Extends confidential communications to counselors,
masters in psychology, nonlicensed psychiatrists, and social workers. Disapproved, since the bill gives
psychiatric social workers and nurses the right to practice medicine without requiring demonstrated
competence to do so.
The Reference Committee recommended that Supplemental Report §1 be filed, with the
exception of the following: S-1272, S-2051, and S-613.
S-1272 — Cody — Generic Substitution/Prescription Blank Change. Active Opposition. Ge-
neric substitution is a questionable concept that must not be advanced without safeguards and
testing. Generic drugs have not been tested through FDA-approved clinical trials. At this time,
the FDA is reviewing the generic issue. Liberalization of the generic law is not indicated at this
time.
The Board of Trustees voted to change the position to No Action, provided the bill is
amended to use the phrase “brand necessary.”
The Reference Committee overwhelmingly supported the original action taken by the Coun-
cil on Legislation.
HOUSE ACTION: Not adopted. The House of Delegates supported the action taken
by the Board of Trustees on May 5, 1990.
S-2051 — Cody — Dispensing of Drugs by Physicians. Active Opposition. Limits physician
ability to treat patient properly. Physicians shall dispense according to existing regulations.
The Board of Trustees voted to change the position to No Action, and to seek certain
amendments and clarification.
The Reference Committee overwhelmingly supported the original action taken by the Coun-
cil on Legislation.
HOUSE ACTION: Not adopted. The House of Delegates supported the action taken
by the Board of Trustees on May 5, 1990.
S-613 — Ewing — AIDS. Approved. Requires person being tested for venereal disease also to
submit to testing for AIDS; requires applicants for marriage licenses to be tested for AIDS.
The Board of Trustees voted to change the position to Disapproved, because mandated
testing for HIV sensitivity would discourage this group of patients from seeking necessary
treatment.
HOUSE ACTION: The House of Delegates supported the action taken by the Board
of Trustees on May 5, 1990.
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Supplemental Report #2
Legislation
IRVING P. RATNER, MD, CHAIRMAN
(Reference Committee “D”)
The Council offers this Supplemental Report #2 covering items dealt with since the compilation of
Supplemental Report #1.
SENATE/ASSEMBLY (Active)
S-1012— Feldman— Medical Malpractice. Provides that within 60 days of filing an action against
a physician, the plaintiff must provide an affidavit from an expert that there has been a negligent deviation
from the accepted standards of practice. Active Support.
S-1233 — Codey — Mental Health Coverage. Requires health insurers to provide coverage for mental
illnesses. Active Support.
S-1234 — Codey — Mental Health Coverage. Requires health insurers to provide coverage for mental
illnesses. Active Support.
S-1235 — Codey — Mental Health Coverage. Requires health insurers to provide coverage for mental
illnesses. Active Support.
S-1236 — Codey — Mental Health Coverage. Requires health insurers to provide coverage for mental
illnesses. Active Support.
S-1237 — Codey — Mental Health Coverage. Requires HMOs to provide coverage for mental illnesses.
Active Support.
S-1238 — Codey — Mental Health Coverage. Requires health service corporations to provide coverage
for mental illnesses. Active Support.
S-1791 — Zane — Unemployment Compensation and Disability Benefits. Exempts physicians who are
independent contractors from employment and disability taxes. Clarifies an ambiguity in the current law.
Active Support.
S-1810 — Bennett — Licensing of Health Professionals. Requires statutory authorization for the
licensure or certification of health care practitioners. Active Support.
A-31 — Kavanaugh — Commissioner of Health. Changes qualifications for commissioner of health and
prescribes qualifications for deputy commissioner of health. Active Opposition, because the health care
needs of our population require that a licensed physician serve in the position of commissioner of health.
There are many qualified candidates. It is not advisable to dilute the requirements at a time when the
nation and New Jersey, in particular, face a major public health crisis caused by drug addiction, AIDS,
and environmental diseases.
A-616 — Felice — Contact Lenses. Creates a State Board of Examiners of Ophthalmic Dispensers and
Ophthalmic Technicians. Permits that Board to license contact dispensers. Active Opposition, the fitting
of contact lenses exposes patients to certain eye injuries. The task, therefore, requires the care, skill, and
experience of optometrists and physicians.
A-1357 — Bryant — Warning Labels. Requires warnings about the dangers of alcohol use by pregnant
women. Active Support.
SENATE/ASSEMBLY (Monitor)
S-1004 — Feldman — Confidentiality of Medical Claims Information. Provides that employers could
not review medical claims submitted by employees on claims through the employers’ coverage. It assumes
that employers discourage claims in order to contain premiums. Applied to Blue Cross. Approved.
S-1005 — Feldman — Confidentiality of Medical Claims Information. Same as S-1004 except it ap-
plies to group health insurance. Approved.
S-1006 — Feldman — Confidentiality of Medical Claims Information. Same as S-1004 except it ap-
plies to Blue Shield. Approved.
S- 1014 — Feldman— Gambling. Directs the Department of Health to establish a center for compulsive
gambling in Atlantic City or some other appropriate area. No Action.
S-1047— Feldman— Cardiopulmonary Resuscitation (CPR). Requires each local board of education
to provide instruction in CPR to all secondary pupils. Conditional Approval, pending amendment of the
bill adding a provision for periodic re-enforcement of CPR education (1 year renewal).
S-1136— Feldman— Sexually Abused Children. Requires the commissioner of human services to
establish two regional treatment centers for sexually abused children. The regional centers would be
networked into community-based model programs and a research institute at one of the schools of higher
education. Approved.
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S- 1 153 — McManimon — Acupuncture. Provides that acupuncturists are eligible for reimbursement
under Blue Shield contracts if the service is otherwise covered. Disapproved, the scientific validity of
acupuncture has not been clearly demonstrated. It would not be prudent to make it a mandated coverage
at this time.
S-l 198 — McManimon — Acupuncturists. Requires health insurers that pay physicians for acupuncture
to pay acupuncturists as well. Disapproved (same as S-l 153).
S-1259 — Codey — Youth Suicide Prevention. Establishes a youth suicide prevention council in the
Department of Human Services. The council shall consist of 12 members. There is no psychiatrist or other
physician specified for appointment. Conditional Approval, pending inclusion of a psychiatric physician
and psychiatric pediatrician to the council.
S- 1261 — Codey — Lupus Registry. Declares lupus a reportable disease and creates a registry within
the Department of Health. Disapproved, already being done on a national level. State Public Health
Council has the authority to establish a registry when public health concerns indicate such a necessity.
S-1262 — Codey — Lupus Treatment. Creates a lupus treatment demonstration project within the
Department of Health with a seven-person advisory committee. Disapproved, education and treatment
program already are being done in physicians’ offices throughout the state.
S-1263-Codey — Medical Waste. Provides for rewards for reports that lead to the conviction of illegal
medical waste disposers. Disapproved, bounty systems encourage reckless conduct. If there is validity to
the concept, it should first be tested for the crimes of murder, rape, and robbery.
S-1269 — Codey — Infection Control Education. Requires institutions that educate allied health pro-
fessionals to incorporate infection prevention and control as part of their program. Disapproved, this
already is being done as standard curriculum. The Legislature should avoid mandating specific course
instruction.
S-1270 — Codey — Laboratory Director’s Licensing. Adds “diagnostic laboratory immunology” to the
list of specialty licenses. Disapproved, there is no indication that sufficient laboratory function and volume
occur for special consideration.
S- 1311 — Jackman — Medical Education. Permits hospitals to enter into educational agreements for
clinical clerkships with any medical school without the prior approval of the State Board of Medical
Examiners. Disapproved, there is no way to authenticate the quality of education in certain foreign medical
schools, therefore, the approval of the State Board of Medical Examiners provides a needed and valuable
counterbalance.
S-1315 — Jackman — Dialysis. Creates a system for training and certifying dialysis technicians. Ap-
proved.
S-1326 — O’Connor — Nutritionists. Provides for the licensing and regulation of nutritionists through
a board of nutrition within the Department of Law and Public Safety. Disapproved, MSNJ generically
is opposed to the creation of new professional boards.
S-1349 — O’Connor — Audiologists/Speech Language Pathologists. Requires health insurers that pay
physicians for services that can be performed by an audiologist or speech language pathologist to pay those
providers as well. Approved.
S-1374 — Bassano — School Buses. Requires school buses to be equipped with seat belts or other
restraint systems approved by the Division of Motor Vehicles. Approved.
S-l 380 — Bassano — Mental Health Records. Requires institutions to make available mental health
records upon request when the patient is an applicant for a police position or firearm permits. Disapproved,
unnecessary legislation — this situation can be addressed by a release signed by the prospective employee
or firearm purchaser.
S-1390 — Bassano — Emergency Medical Services. Requires that one EMT be on paid, municipal,
or hospital-based ambulances rather than two as currently are required. Approved.
S-1434 — Bassano — Drug Testing Student Athletes. Requires school boards to establish random drug
testing programs for student athletes. Testing would be done at school board expense. Disapproved, the
issue of drug abuse in the school extends beyond the scope of the student athlete. This bill, therefore,
would, send the wrong message and ignore the need to educate and test beyond the athlete population.
S-l 547 — Cardinale — Monosodium Glutamate. Requires restaurants to notify customers if they use
monosodium glutamate in preparation of their food or add it to the food after preparation. Notice would
be in writing on, or attached to, the menu. Conditional Approval, pending inclusion of all papain
derivatives. (Doctor Kerlin voted in the negative and is so recorded.)
S-1548 — Cardinale — School Health. Requires periodic examinations of school children for obesity.
Disapproved, no special examination is necessary, the annual physical examination does include obesity
evaluation.
S-1562 — Cardinale — Radiation Protection Commission. Adds two members expert in medical phys-
ics and epidemiology to the Radiation Protection Commission. Approved.
S-l 568 — Cardinale — Marriage License Certificate. Requires applicants to be tested for thalassemia,
sickle cell anemia, and Tay-Sachs. The physician must notify the applicants of the test results in writing.
Disapproved, because two far more universal diseases — diabetes and rubella — are not included in the
testing and those listed have a limited population susceptibility. The tests themselves would not be
medically indicated for a majority of applicants.
S-1570 — Cardinale — Alcoholic Beverages. Requires that alcoholic beverages be labeled to advise of
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potential harm to fetuses when consumed by pregnant women. Approved.
S-1586 Cardinale Education. Requires public schools with sex education programs to emphasize
that abstinence is the best assurance of avoiding sexually transmitted diseases and pregnancy. No Action.
S-1592 Cardinale Fluoride. Prohibits the addition of fluoride to the water of adult psychiatric
facilities that have independent water sources. Action Deferred, pending further information from MSNJ’s
Council on Mental Health.
S-1663— Dorsey— Campaign Contributions. Limits PACs to contributions of $2500 in state Assembly
and Senate elections. Disapproved, limiting the amount that a PAC could contribute to a legislative
candidate would disadvantage the individuals who pool their resources in a PAC.
S-1664 Dorsey — Lobbyists. Limits lobbyists from expending more than $2,500 annually on any given
legislator, the governor, or his staff. No Action.
S-1706 Dorsey Fetal Deaths. Requires hospitals to advise patients of the options regarding the
disposition of fetal remains when death occurred at or beyond 20 weeks of gestation. No Action.
S-1747 Zane — Organ Transplants. Establishes a commission on transplants to allocate transplant
services for New Jersey residents. Out-of-state programs are not recognized if the service is available at
a New Jersey hospital. No Action.
S-1899— Dumont— Physical Therapy. Requires physical therapy treatment to be given under the
supervision of a practitioner authorized to prescribe treatment. “Supervision” is defined as personally
monitoring the progress of treatment and includes intermittent observation of treatment sessions. Con-
ditional Approval, pending amendment of the bill to read— on line 19 after the word treatment insert
[shall periodically review the progress of the treatment.] and delete [shall personally monitor the progress
of that treatment, including on an intermittent basis, the personal observation of the physical therapy
treatment as it is being administered by the physical therapist.].
S-1947— Orechio— Drug Abuse Treatment. Requires health insurers and HMOs to include coverage
for drug abuse treatment as for any other illness. Approved.
S-1948— Orechio— Drug Abuse Treatment. Same as S-1947. Approved.
S-1949— Orechio— Drug Abuse Treatment. Same as S-1947. Approved.
S-1950— Orechio— Drug Abuse Treatment. Same as S-1947. Approved.
S-1951— Orechio— Drug Abuse Treatment. Same as S-1947. Approved.
S-2003— Orechio— AIDS. Requires the Department of Health to file reports related to ARC, AIDS,
and HIV positive patients to local health officers on a regular basis. Disapproved, local health officers
currently have access to these statistics.
S-2053 — Lesniak — Audiologists. Allows an audiologist to dispense hearing aids without having to be
licensed as a hearing aid dispenser. Action Deferred, pending further information from the New Jersey
Academy of Ophthalmology and Otolaryngology.
S-2183 — McNamara — Health Insurance Mammograms. Requires health insures to provide coverage
for mammograms. Approved.
S-2197 — Dalton — Health Insurance. Directs health insurers to provide insured with a written state-
ment of the application of the policy to injuries sustained in automobile accidents. Approved.
S-2198 — Dalton — HMOs. Requires HMOs to give enrollees a statement of available coverage regarding
automobile accidents. Approved.
S-2282 — Bassano — Anabolic Steroids. Classifies anabolic steroids as a “schedule V” drug. Action
Deferred, pending further information from the New Jersey Department of Health and MSNJ’s Committee
on Physicians’ Health.
S-2361 — Cardinale — Controlled Dangerous Substances. Requires the testing of applicants for motor
vehicle driver’s licenses for the use of controlled dangerous substances. No Action.
S-2379 — Thomas — Autopsy. Deletes the requirement that a consent to an autopsy must be in writing.
Approved.
S-2399 — Russo — Drug Permits. Amends the CDS registration cycle to three years to coincide with
federal CDS cycles. Approved.
SJR-6 — Graves — Health Care Facilities and Providers. Establishes a commission to study the
feasibility of an expanded system of hospital-based nursing schools. No MSNJ representation is provided.
Conditional Approval, pending amendment adding a physician to commission.
A-16 — Naples — New Jersey Advance Directives for Health Care Act. This year’s version of the
advance directives bill (also known as the “living will”). Approved.
A-239 — Naples — School Bus Seat Belts. Requires all new school buses to have seat belts and man-
dates that students use them. Approved.
A-328 — Deverin — T.B. Test for Nursing Home Employees. Requires that all current and prospective
employees of nursing homes be tested for tuberculosis. Approved.
A-334 — Deverin — Professional Liability Insurance. Allows organizations of professionals to form
associations to self-insure professional liability. The entities created would be under special regulatory
control of the Insurance Department, but are not to be considered insurance companies. Disapproved,
because the program would not protect the public by assuring adequate financing of insurance mechanisms.
Professional associations should be encouraged to form insurance carriers consistent with code.
A-353 — Colburn — Certificate of Need. Exempts outpatient services with a cost of less than $2 million
from the certificate of need law. Additionally, joint ventures with two or more doctors with a cost less
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than $4 million would be exempt from certificate of need. Approved.
A-354 — Colburn — Nursing Services. Provides that the costs associated with nursing services must
be specifically identified in hospital budgets and rating formulas. Approved.
A-377 — Rooney — Motor Vehicles. Adds visual field to the driver’s license test. Disapproved, extreme-
ly difficult and expensive to administer such tests.
A-410 — Rooney — Preschool Vision Screening. Establishes a preschool vision screening for children
three to five years of age. Approved.
A-412 — Rooney — Nutritionists. Licenses and regulates the practice of nutrition and creates a state
board of nutrition. Disapproved, no demonstrated need to create a licensed profession in this field.
A-543 — Impreveduto — Preschool Hearing Screening. Establishes a hearing screening program for
preschool children. Approved.
A-546 — Impreveduto — Physical Modalities. Provides that physicians, podiatrists, and chiropractors
may not use unlicensed aides to administer ultraviolet (B and C bands) and electromagnetic rays. Ap-
proved.
A-578 — Felice — Prevention of Child Abuse. Creates a 24-member commission to study the problem
of child abuse and to recommend methods of prevention. Conditional Approval, pending the inclusion
of a pediatrician and a psychiatrist on the commission.
A-597 — Felice — Osteoporosis Study Commission. Establishes a commission (15 members) to compile
and analyze data on osteoporosis, develop educational programs, and assist local health agencies in public
education. Disapproved, because osteoporosis is a well-known, researched, and publicized condition, and
there is no need to create a special legislative commission to conduct studies when comprehensive, scientific
literature readily is available.
A-608 — Felice — Food and Hydration. Requires food, water, nourishment, and hydration be provided
to all patients. Disapproved, an unnecessary barrier to patient expressions — (MSNJ— December 8, 1988)
“MSNJ believes the artificial administration of nutrition and hydration should be in the definition of life-
sustaining treatment that can be ethically withdrawn from permanently comatose vegetative patients.”
A-615 — Felice — Certificate of Need. Requires the Department of Health to hold public hearings on
all certificate of need applications. No Action.
A-617 — Felice — Medical Waste. Requires hospitals to package special medical waste in red bags
marked with the international bio-hazard warning symbol and inscription. Disapproved, this legislation
is adequately covered under the Comprehensive Medical Waste Management Act.
A-761 — Duch — Home Health Care. Establishes a demonstration project within the Department of
Human Services to provide home health care to functionally and cognitively impaired seniors or disabled
persons under the Social Security Act. No Action.
A-800 — Bush — AIDS. Requires that AIDS and AIDS-related conditions be reported to the Department
of Health. Information may be released only when patient consent or certain other situations are present.
No Action (current law).
A-802 — Bush — Medicaid. Provides that Medicaid coverage for mammograms shall be consistent with
federal policy. Conditional Approval, pending amendment that coverage also be consistent with current
recommendations of the American Cancer Society.
A-803 — Bush — Health Insurance. Provides that health insurers must pay for mammograms. It does
not apply to routine screening. Conditional Approval, pending inclusion of routine screening and is
consistent with the recommendations of the American Cancer Society.
A-828 — Bush — Infant Mortality. Creates a commission on infant mortality consisting of 15 members;
4 members would be physicians. Approved.
A-829 — Bush — Cancer Research. Provides that a portion of the surtax on cigarettes be dedicated
to the Cancer Research Fund. Approved.
A-844 — Bush — Sickle Cell Anemia. Requires that all infants born in the state shall be tested for
sickle cell anemia and other hemoglobinopathies. Disapproved, pediatricians could better determine who
needs the testing and who does not need the testing. Most babies and families would not benefit from
such tests.
A-855 — Villapiano — Dioxin Research. Creates a special “consortium” to conduct research on dioxin
contamination. Appropriates $2,000,000. Disapproved, data is already known, research is being done, and
the issue is better addressed at the federal level.
A-870 — Villapiano — Emergency Medical Transportation. Requires the Department of Health to
notify county health departments of all persons residing in the county that are HIV positive. The county
health department is to pass the list on to each EMS transport provider. A similar notice by hospitals
is to be given to EMS transport when an HIV positive patient is leaving that hospital by EMS transport.
Disapproved, unenforceable and unworkable legislation. County health departments are not prepared to
administer such a proposal.
A-893 — Otlowski — Certificate of Need. Exempts home health agencies from the CON law. Approved.
A-922 — Otlowski — Drug Abuse Treatment. Makes drug abuse treatment an included item under
medical service corporations. Approved.
A-923 — Otlowski — Drug Abuse Treatment. Same as A-922 except it applies to commercial health
insurance. Approved.
A-924 — Otlowski — Drug Abuse Treatment. Same as A-922 except it applies to group health in-
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surance. Approved.
A-925 — Otlowski — Drug Abuse Treatment. Same as A-922 except it applies to HMOs. Approved.
A-926 — Otlowski — Drug Abuse Treatment. Same as A-922 except it applies to hospital service
corporations. Approved.
A-966 — Cohen — Blood Donation. Creates a separate criminal offense for making a blood donation
while knowingly infected with a communicable disease. Disapproved, this legislation, as written, will create
an overall negative impact in the blood donor programs.
A-1075 — Brown — Infant Mortality. Creates an infant mortality prevention program in the Depart-
ment of Health to provide obstetrical and prenatal services to women with high-risk pregnancies. Also
provides postpartum followup services. Seven hospitals are designated by statute with three to be added
by the commissioners. Two million dollars is appropriated. Approved.
A-1107 — Schuber — Compulsive Gambling. Establishes an office on compulsive gambling within the
Department of Health and a 13-member advisory council. No Action.
A- 1483 — Stuhltrager — C hild Abuse Diagnostic Center. Establishes a child abuse diagnostic center
in southern New Jersey. Approved.
A- 1556 — Girgenti — Orthotists and Prosthetists. Provides for the licensing and regulation of orthotists
and prosthetists through an advisory committee in the Division of Consumer Affairs. Physicians are
exempted from the requirements of the act. Disapproved, there has not been a demonstrated need to
license and regulate this as a profession.
A-1572 — Girgenti — Medical Records. Requires hospitals and physicians to provide patients with
copies of their records within 30 days of a request by the patient or their representative. Disapproved,
conditions of this bill already covered by SBME regulations.
A-1630 — Shusted — Medicaid: Patterning. Requires Medicaid coverage of patterning. Disapproved,
because patterning has not been scientifically accepted and is both controversial and experimental.
A-1631 — Shusted — Civil Immunity. Provides that volunteer officers and directors of nonprofit corpor-
ations shall be immune from certain types of suits. Approved.
A-1646 — Shusted — Peer Review. Adopts the provisions of the Federal Health Care Quality Improve-
ment Act with the immunities granted. (The federal law which grants immunities also has certain required
reporting.) No Action.
A-1713 — Smith — Lupus Registry. Establishes a lupus registry and requires physicians to report all
known cases to the registry. Disapproved, the State Public Health Council has the authority to establish
a registry if indicated.
A-1714 — Smith — Lupus Treatment. Directs the Department of Health to establish a lupus treatment
and education program and appropriates $750,000. Disapproved, already being done in physicians’ offices
and hospitals throughout the state.
A-1773 — McEnroe — Infants: Drug Abuse. Requires the Department of Health to prepare, and phy-
sicians to distribute, a booklet concerning the dangers of using cocaine during pregnancy; appropriates
$75,000. Disapproved, physicians caring for pregnant women regularly warn against the use of tobacco,
alcohol, and other drugs during pregnancy. State-of-the-art literature is available from a wide range of
national scientific sources. The Department of Health does not have the capacity to produce, distribute,
and maintain materials of comparable quality.
A- 1881 — Doria — Podiatry. Permits podiatrists to certify physical disability for handicapped parking
privileges. Approved.
A-2035— Ogden — Emergency Medical Transport. Requires health care facilities to notify first aid,
ambulance, and rescue squads that they are transporting patients with AIDS, HIV positivity, or com-
municable disease. Action Deferred, pending further information from MSNJ’s Task Force on AIDS.
A-2139 — Rocco — Fetal Remains. Requires that fetal remains be examined by a pathologist who shall
report his findings to the referring physician. Remains not disposed of by interment shall be incinerated
pursuant to Department of Health regulation. Action Deferred, pending further information from the New
Jersey Obstetrical and Gynecological Society and New Jersey Society of Pathologists.
A-2141 — Rocco — Physiological Laboratory Services. Provides that physiological laboratories per-
forming diagnostic testing services at the request of physicians shall be permitted to bill Blue Shield
directly. Disapproved, because there are no announced licensing standards in the bill. The New Jersey
Insurance Department is not equipped to regulate and license a health profession. There is no recognized
profession related to “physiological laboratory services.”
A-2169 — Rocco — Hypodermic Needles/Syringes. Increases the penalty for the illegal disposal of
hypodermic needles and syringes. Disapproved, current law adequately addresses the concern of this
legislation.
A-2211— Spadoro— AIDS Vaccine. Creates the AIDS vaccine and drug research and development
grant program. Action Deferred, pending further information from MSNJ’s Task Force on AIDS.
A-2261—Farragher— Trucking/Food/Waste. Prohibits transporters from hauling solid wastes,
produce, or other items intended for human consumption in the same vehicle. Approved.
A-2267 — Farragher — Professional Licensing. Provides that a conviction under the Comprehensive
Drug Reform Act shall automatically result in a two-year suspension of license or business permit. Ap-
proved.
A-2270— Farragher— Parental Notification for Abortion. Requires physicians to notify, in writing,
NEW JERSEY MEDICINE
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the parents of unemancipated minors (less than 18) 72 hours prior to an abortion. Action Deferred, pending
further information from New Jersey Obstetrical and Gynecological Society.
A-2271 — Arnone — Blood Donations. Eliminates age restrictions on blood donations. Approved.
A-2340 — Franks — Motor Vehicles/Drug Tests. Requires the Division of Motor Vehicles to establish
a three-year random sample drug testing program for applicants for a driver’s license. No Action.
A-2404 — Baer — Sulfites. Prohibits wholesale or retail distributors of food or food products from adding
sulfites to their products. Action Deferred, pending further information from MSNJ’s Council on Public
Health.
A-2481 — Randall — Outpatient Drug and Alcohol Treatment. Requires standards for outpatient
adolescent drug and alcohol treatment programs. Conditional Approval, pending inclusion of two MSNJ
appointed physicians to the advisory task force.
A-2485 — Randall — Smoking/Restaurants. Requires restaurants with a seating capacity of 80 or more
to have a 50 percent nonsmoking area. Approved.
A-3042 — Bush — Medicare Assignment. Requires mandatory assignment for PAAD eligible patients.
Conditional Approval, pending the following amendments: presentation of PAAD cards; lower penalty
violations; and recognition that physicians must bill for deductibles and copayment consistent with federal
law.
The Reference Committee recommended that Supplemental Report § 2 be filed.
HOUSE ACTION: Adopted. Supplemental Report #2 was filed, in accordance with the
positions taken by the Council on Legislation.
At its meeting on May 5, 1990, the Board of Trustees changed the Council on Legislation’s
position on the following bill:
A-3042 — Bush — Medicare Assignment. Requires mandatory assignment for PAAD eligible
patients. Conditional Approval, pending the following amendments: (a) presentation of PAAD
cards; (b) lower penalty violations; and (c) recognition that physicians must bill for deductibles
and copayment consistent with federal law.
The Board of Trustees voted to change the position to Active Opposition; there is a
successful voluntary effort to assure care to the poor. This legislation interferes with the constitu-
tional rights of doctors and patients.
HOUSE ACTION: The House of Delegates supported the action taken by the Board
of Trustees on May 5, 1990.
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NEW JERSEY MEDICINE
Resolution #2
Introduced by:
Subject:
Referred to:
Essex County Medical Society
Alternative to Tort Reform
Reference Committee “D”
Whereas, we should continue to pursue traditional tort reform such as structured settlements
and the statute of limitations; and
Whereas, Utah and Vermont are developing administrative action initiatives to handle
professional liability to assure injured patients of reasonable damages on a compensation-type
program; and
Whereas, Florida and Virginia have no-fault compensation laws covering some neurologically
impaired infants; and
Whereas, other states are seeking legislation authorizing arbitration and/or the use of private
contracts between providers and patients to govern professional liability; now therefore be it
Resolved, that an ad hoc committee of the Medical Society of New Jersey be established
to coordinate tort reform objectives and to look into realistic alternatives to tort reform that
would work in New Jersey.
The Reference Committee recommended that Resolution § 2 be adopted.
HOUSE ACTION: Adopted. Resolution #2 was adopted.
NEW JERSEY MEDICINE
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Resolution #23E
introduced by:
Subject:
Referred to:
Essex County Medical Society
Oppose Physician Assistants
Reference Committee “D"
Whereas, the Medical Society of New Jersey House of Delegates has consistently rejected
the licensing, registration, or use of physician assistants in New Jersey; and
Whereas, a task force of the New Jersey State Board of Medical Examiners has recom-
mended a pilot project using physician assistants; and
Whereas, New Jersey is not a rural state and is well populated with physicians and nurses;
and
Whereas, nurses perform all duties of physician assistants; and
Whereas, the licensing of physician assistants would only dilute the diligent services per-
formed by physicians; and
Whereas, the use of physician assistants will not improve on cost, quality, or accessibility
of patient care; now therefore be it
Resolved, that the Medical Society of New Jersey continue actively to oppose any licensing
or utilization of physician assistants -a-nd any pilot projects proposed by the State Board of
Resolved, that the Medical Society of New Jersey oppose any pilot projects proposed by
the State Board of Medical Examiners to legalize physician assistants in New Jersey.
The Reference Committee recommended that the resolved portion of Resolution #23E be
amended (with correction in first resolved and the addition of the second resolved).
The Reference Committee recommended that Resolution #23E be adopted as amended.
HOUSE ACTION: Adopted. Resolution #23E was adopted as amended by the Reference
Committee.
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NEW JERSEY MEDICINE
Resolution #24E
Introduced by:
Subject:
Referred to:
F. Peter Rescigno, MD, Delegate,
Essex County
Representation on Governor’s Commission on Health Care Costs
Reference Committee “D”
Whereas, Governor Florio has unveiled to the press a newly formed Commission on Health
Care Costs as disclosed in the Newark Star-Ledger on April 19, 1990; and
Whereas, this Commission according to Governor Florio “will deal with all the health care
issues: access, cost, and quality”; and
Whereas, this Commission consisting of 18 members has no member (or members) who
officially represent the Medical Society of New Jersey; and
Whereas, the issues being addressed will intimately affect every physician in the state; and
Whereas, those most intensely affected should have adequate and substantial represen-
tation; and
Whereas, Governor Florio, the Commission on Health Care Costs, and the state legislature
cannot solve the state’s health care cost crisis on the backs of the physicians of the state of
New Jersey; now therefore be it
Resolved, that the Medical Society of New Jersey aggressively seek substantial and ade-
quate representation on Governor Florio’s Commission on Health Care Costs; and be it further
Resolved, that the Medical Society of New Jersey seek representation on all governmental
committees dealing with health care issues in New Jersey; and be it further
Resolved, that the Board of Trustees and the Council on Public Relations use their best
efforts to make the public aware that there are no representatives of organized medicine on the
Governor’s Commission on Health Care Costs.
The Reference Committee recommended that Resolution #24E be adopted as amended
(with the addition of a second resolved).
HOUSE ACTION: Adopted. Resolution #24E was adopted as amended by the Reference
Committee, with an additional amendment (the third resolved) by the House of Delegates.
NEW JERSEY MEDICINE
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Resolution #25E
Introduced by: F. Peter Rescigno, MD, Delegate,
Essex County
Subject: Information Regarding Health Care Costs
Referred to: Reference Committee “D”
Whereas, the Commission on Health Care Costs, announced to the press by Governor Florio
on April 19, 1990, has no official representation and participation by the Medical Society of
New Jersey; and
Whereas, the Commission consists of at least one member who has publicly declared his
position strongly favoring mandated fees to New Jersey physicians; and
Whereas, Governor Florio is forcefully fulfilling his campaign-stated goals with the immense
power of a Democratically controlled state legislature behind him; and
Whereas, the Governor has focused the burden and financial penalty for the state automobile
insurance crisis on the insurance companies, thereby establishing the implication in the public
mind that they are the primary cause for the crisis; now therefore be it
Resolved, that the Medical Society of New Jersey launch a massive campaign to inform
the politicians and the public that physicians will not be held accountable for the health care
cost crisis and under no conditions will tolerate attempts by the state to enslave them.
HOUSE ACTION: Resolution #25E was not accepted as an emergency resolution.
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NEW JERSEY MEDICINE
Committee on Revision of
Constitution and Bylaws
JAMES E. GEORGE, MD, JD, CHAIRMAN
(Reference Committee on Constitution and Bylaws)
PROPOSED AMENDMENTS TO THE BYLAWS
1. Emeritus Membership
The Committee on Constitution and Bylaws was requested by the House of Delegates to
reconsider the issue of emeritus membership. In addition, Resolution #11 from the 1989 House
of Delegates also was referred to us for review.
The Committee has concluded that any physician, regardless of age or reason, who has
retired from active practice should be considered for emeritus status. Likewise, we have de-
termined that physicians in the emeritus category should pay dues at a reduced level unless
there is financial hardship. Our proposal provides for the changes discussed; i.e. beginning with
the year 1991, all members who retire may be “emeritus” and those who select that category
should pay 25 percent of the regular dues, unless they experience financial hardship.
Chapter I — Membership
Section 1 — Composition
Current
(d) Emeritus Members
Emeritus members shall be physicians who have
been members in good standing of a component
society and who by reason of age or infirmity have
retired from the active practice of medicine; or
members of this Society who have been disabled
by reason of military service. Nominations shall be
submitted by the component societies, and
emeritus membership shall be conferred by a ma-
jority vote of the House of Delegates. Emeritus
members shall have all the privileges of member-
ship except the right to vote and hold office, and
their respective component societies shall not be
assessed for such members provided they are car-
ried as emeritus members in said component so-
cieties. Emeritus members shall not be included in
the membership of a component society when com-
puting the number of delegates to which such so-
ciety is entitled. Active practice shall be de-
termined by policy decision of the Board of
Trustees or the House of Delegates.
Proposed
(d) Emeritus Members
Emeritus members shall be physicians who have
been members in good standing of a component
society who have retired from the active practice
of medicine; or members of this Society who have
been disabled by reason of military service. Nomi-
nations shall be submitted by the component so-
cieties, and emeritus membership shall be con-
ferred by a majority vote of the House of Delegates.
Emeritus members shall have all the privileges of
membership except the right to vote and hold of-
fice. Emeritus members elected after January 1991
shall pay 25 percent of the regular dues assessment
unless they have been exempted for financial hard-
ship as defined in Chapter X — Finance, Section
1 — Annual Dues, paragraph (d).
The Committee on Revision of Constitution and Bylaws recommends adoption of the Bylaw
proposal.
2. Annual Dues
As directed, the Committee has also reviewed the Bylaws applicable to annual dues. All
ramifications were reviewed. Our conclusion is that any member who experiences financial
hardship because of disability or illness should be dues exempt. Likewise, any member who has
suffered financial hardship for other reasons recognized by a county society should be dues
exempt. We also concluded that the automatic dues exemption at age 70 is not fair to younger
members. We are proposing, therefore, that members between ages 70 and 80 pay the same dues
as emeritus members (25 percent). After age 80, all members would be dues exempt.
NEW JERSEY MEDICINE
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Chapter X — Finance
Section 1 — Annual Dues
Current
(d) Dues shall not be levied against any member
in good standing if:
1. He shall have attained the age of seventy
(70) years; or
2. They are serving in the armed forces of the
United States as draftees, or as volunteers in
times of military conflict; or
3. He is a member emeritus; or
4. The payment of dues would be a financial
hardship by reason of physical disability or
illness. A member also may be excused from
payment of dues because of financial hard-
ship for other reasons, but these reasons
must be set forth annually by the secretary
of the member’s component society.
Proposed
(d) Dues shall not be levied against any member
in good standing if:
The payment of dues would be a financial
hardship by reason of physical disability or
illness. A member also may be excused from
payment of dues because of financial hard-
ship for other reasons, but these reasons
must be set forth annually by the secretary
of the member’s component society.
(e) As of January 1, 1991, the dues structure for
all active members shall be:
1. Members under age 70 will pay full dues.
2. Members between ages 70 and 80 will pay 25
percent of full dues.
3. Members above age 80 shall be dues exempt.
The Committee on Revision of Constitution and Bylaws recommends adoption of the Bylaw
proposal.
In discussing the proposed amendments to the Bylaws, the Reference Committee noted that
emeritus members will continue to receive all membership benefits such as: the Physicians’
Health Program, insurance participation, and service on the Society’s councils and committees.
Adoption of the proposed amendment also will help to assure financial stability of the
Society and provide for these physicians a reduced and reasonable rate of payment. These
changes will be totally prospective in nature. Physicians presently in the emeritus category
automatically will be grandfathered.
In all categories where members pay dues, exemptions will always be available for those
who have suffered financial hardship or distressful circumstances.
The Reference Committee recommended adoption of the proposed amendment to Chapter
I — Membership, Section I — Composition, item (d) Emeritus Members.
HOUSE ACTION: Not adopted.
The Reference Committee recommended adoption of the proposed amendment to Chapter
X — Finance, Section I — Annual Dues, items (d) and (e).
HOUSE ACTION: Adopted. The proposed amendment was adopted.
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NEW JERSEY MEDICINE
Resolution #22E
Introduced by: Hudson County Medical Society
Subject: Term of AMA Delegates and Alternates
Referred to: Reference Committee on Constitution and Bylaws
Whereas, the Bylaws of the Medical Society of New Jersey specify a maximum tenure of
12 years as AMA delegate and/or alternate delegate; and
Whereas, the success of a delegation is closely related to the visibility of its members; and
Whereas, in a body which meets only twice a year, widespread recognition can be achieved
only after several years; and
Whereas, no other state medical society has a similar restriction on its AMA delegation
tenure; now therefore be it
Resolved, that the restriction on tenure of the AMA delegation be removed; and be it further
Resolved, that the Bylaws be amended accordingly.
HOUSE ACTION: Resolution #22E was not accepted as an emergency resolution.
NEW JERSEY MEDICINE
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Memorial Resolution
FRANK R. BEGEN, MD, 1926-1989
Whereas, the Almighty has chosen to call from us our beloved colleague, Frank R. Begen,
MD; and
Whereas, as a Fellow and Officer of this Society, Doctor Begen served its members and
the people of New Jersey; and
Whereas, he demonstrated the attributes of a concerned and caring father, husband, and
physician, and will be missed by all; now therefore be it
Resolved, that the Medical Society of New Jersey expresses its profound sorrow at the death
of Doctor Begen and extends its sympathy to his family; and be it further
Resolved, that this Resolution be spread upon the minutes of this meeting and a copy
thereof presented to his family in heartfelt sympathy.
Received by the House with sorrowful concurrence.
Memorial Resolution
PETER SWEETLAND, 1935-1990
Whereas, the Almighty has called from us his servant, Peter Sweet land; and
Whereas, as the president and chief operating officer of the New Jersey State Medical
Underwriters, Mr. Sweetland served this Society and its insured physician membership; and
Whereas, by his example and leadership he demonstrated the attributes of a dedicated
executive and manager; and
Whereas, by his strength of character and demeanor he proved an outstanding leader in
the field of professional liability insurance; and
Whereas, as a husband and father he was caring and supportive to his family; now therefore
be it
Resolved, that the Medical Society of New Jersey expresses its profound sorrow at the death
of Peter Sweetland and extends its sympathy to his beloved family; and be it further
Resolved, that this Resolution be spread upon the minutes of this meeting and a copy,
suitably prepared, be presented to his bereaved family in heartfelt sympathy.
Received by the House with sorrowful concurrence.
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NEW JERSEY MEDICINE
Informational Report
Senior Citizens Task Force
IAN D. SAMSON, MD, CHAIRMAN
The first meeting of the reconstructed Task Force was held on March 22, 1989. A new set
of directives was given to the Task Force by the Board of Trustees. These included the provision
for at least 1 senior representative of each county, approved by the county medical society. The
Task Force was constituted of 18 seniors representing 12 counties; 22 representatives of the 21
County Offices on Aging; 21 county medical society executives; 20 physicians representing 18
counties, and 2 medical students, as well as 13 representatives of 12 other institutions and
agencies.
A meeting then was held on April 12, 1989. Subsequent meetings were held on June 29,
August 17, October 25, 1989, and January 10 and April 11, 1990. A great disappointment was
the poor turnout of seniors at meetings. An exception was the October meeting, which was
highlighted by keynote speakers associated with gubernatorial election. There were never more
than 14 seniors present representing 12 counties. The lowest attendance was 11 seniors rep-
resenting 5 counties. Counties not represented were contacted for names of senior representatives,
but to no avail. This issue will be developed in the conclusion of this report.
The Task Force was directed to establish two subcommittees. The first was to investigate
and report on the financing of health care delivery. The second was to attend to publicity and
communication to ensure that the activities of the Task Force be disseminated as widely as
possible. Unfortunately these subcommittees never functioned. However, the Task Force did
generate a bulletin sent to 10,000 physicians. The missive contained suggestions to improve
relations between physicians and their senior patients. The number of replies to a questionnaire
in the bulletin was disappointing.
In order to address issues of conflict between physician providers, seniors, and third-party
payers, each group represented on the Task Force was instructed to collate data and present
their findings. In this respect the Task Force was successful. As a result of this effort a list of
grievances was assembled. The majority were directed against Medicare and its carrier, Penn-
sylvania Blue Shield. A representative of Pennsylvania Blue Shield presented the provider’s case
and was subjected to intense questioning. A formal letter then was sent to HCFA summarizing
recipient and physician complaints and suggesting remedial action. We have received a response
from the regional office indicating their support for our comments.
Legislation relating to expenditure targets was discussed at length and a formal letter of
protest was sent to our senators and congressmen. Responses were received from a number of
congressmen, but by no means all. Neither of our senators responded to our letter.
A symposium on “living wills” resulted in near unanimous support for this concept by seniors
and physicians alike. A letter has been drafted on behalf of members of the Task Force and
will be sent to members of the New Jersey Assembly appraising them of our support for such
legislation.
CONCLUSION
All the objectives of the Task Force were not met. It was, however, the consensus of the
membership that the Task Force did serve a useful purpose in providing a forum for airing the
problems of physicians, agencies, and seniors. It was decided that the bulletin to physicians
be continued, not as an individual mailing, but as an item in NEW JERSEY MEDICINE.
Concern was expressed about the small representation on the Task Force by seniors. It is
felt that this deficiency needs correction if the Task Force is to have a meaningful impact on
our senior community. Therefore, we will enlist the support of the Offices on Aging to supply
us with senior representatives. Up to four seniors per county will be asked to sit on the Task
Force. They should be responsible members of local senior clubs and organizations.
NEW JERSEY MEDICINE
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PLANNING FOR 1990/1991
In order to assess the impact of the Task Force on seniors’ constituencies, we would require
feedback from their representatives in the form of bulletins and minutes. In this manner the
Committee on Senior Citizens will be able to judge the effectiveness and significance of the Task
Force.
The Task Force will meet four times a year. A featured speaker, address, or debate on items
of mutual interest will be held on each occasion. We will continue to monitor legislation, public
health matters, and concerns relating to senior citizens and act responsively.
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NEW JERSEY MEDICINE
Informational Report
Task Force on the Shortage of Nurses and Technical Personnel
JOHN S. MADARA, MD, CHAIRMAN
The Task Force on the Shortage of Nurses and Technical Personnel was formed in response
to Substitute Resolution $20 (1988) Solving the Nursing Shortage. Representatives of various
branches of nursing— including the University of Medicine and Dentistry of New Jersey, the
New Jersey State Nurses Association, the Licensed Practical Nurse Association of New Jersey,
Inc., the New Jersey Hospital Association, the New Jersey State Department of Health, and
nonaligned nurses — attend meetings of the Task Force, and representatives from the allied health
field recently were added as consultants.
Three major areas of need were identified to address the shortage of nursing and technical
personnel: funding, retention, and recruitment. An interim report, listing the accomplishments
of the Task Force was made to the Board of Trustees on September 17, 1989, and a recommen-
dation that the Society adopt the following listed policies was approved by the Board:
1. Registered Care Technician (RCT). The proposal of the AMA should not be im-
plemented in New Jersey at this time.
2. Salaries. Nurses’ salaries should be competitive with contiguous states.
3. Physician-Nurse Collaboration. Communication/collaboration between physicians and
nurses should be strongly encouraged.
4. Non-Nursing Functions. Nurses should be relieved of non-nursing functions, and guide-
lines implemented to reduce time spent in excessive documentation requirements.
5. Acute Care Nursing Assistant Program. Funding should be sought for implementation
of the ACNA program proposed by UMDNJ-Department of Nursing Education and Services,
endorsed by the Medical Society of New Jersey (Board of Trustees, October 16, 1988), and the
New Jersey Hospital Association as a method to relieve the task load of professional nurses in
acute care institutions.
6. NJHA Nursing and Allied Health Resource Center. The Resource Center should be
supported as an information clearinghouse and referral source for individuals interested in
nursing and allied professions.
7. Scholarships. Health career scholarships and tuition forgiveness programs should be
encouraged for individuals interested in nursing and allied health careers.
8. Support Personnel. Sufficient support personnel must be provided so that nurses can
focus on providing, supervising, and coordinating quality nursing care. Licensed practical nurses
(LPNs) should be utilized at all levels of hospital care; they should be permitted to perform
such additional patient care procedures as defined by the expanded scope of practice permitted
by the State Board of Nursing.
9. Graduate Nurses Who Fail Board Examinations. In order to facilitate retention, a
means should be found to extend work permits, with limitations, to allow graduate nurses who
fail their board examinations to function in the graduate nurse capacity, until they retake the
examination.
10. Work Environment. Hospitals should be encouraged to provide child care for women
returning to the workplace, and extra pay for the more difficult or less desirable shifts.
11. Allied Health Personnel. Monies should be made available to provide hospitals with
sufficient reimbursement funds to recruit and retain allied health personnel. Educational op-
portunities, with flexible and innovative programs, scholarship programs, and long-term agree-
ments should be offered. Setting higher standards to enter the curriculum, providing counseling,
and offering flexibility according to student needs also should be encouraged. Career pathways
should be bolstered.
12. Restructuring of Health Care Givers in Hospital Environment. Restructuring should
be established, with nursing professionals having greater autonomy in an administrative and
NEW JERSEY MEDICINE
Tr77
clinical sense, and cooperating with physicians in establishing parameters to supervise the
delivery of patient care rendered by LPNs and certified nursing aides.
13. Foreign Nurses. Recruitment of nurses from other countries should be considered.
14. Recruitment at the High School Level. Publicity campaigns should be conducted by
appropriate professional organizations in cooperation with technological societies, county medi-
cal societies, and specialty groups to stimulate interest in allied health careers at the high school
level.
15. Hospital-Based Educational Programs. Hospitals should be encouraged to open
schools of technology in multiple fields. Funds should be sought to encourage hospitals in
underprivileged areas to offer high school graduates opportunities to enter allied health pro-
fessions for a reasonable (or minimal) tuition, and in their local communities. Tuition waivers
to further education for those volunteering to work a certain number of years at a hospital should
be encouraged.
16. Courses in Interpersonal Relationships and Stress Management. Courses should be
encouraged in interpersonal relationships and stress management through the offices of ap-
propriate professional organizations.
Former Acting Commissioner of Health, Leah Z. Ziskin, MD, MS, evinced a high level of
interest and enthusiasm for nursing issues. Her letter to the Society in response to the recommen-
dations of the Task Force reflected the views of the Department of Health and the Department’s
Nursing Advisory Committee.
Additional topics considered by the Task Force include:
1. Nursing Models Incentive Reimbursement Program. The recommendation of the Task
Force that the Society support the Nursing Models Incentive Reimbursement Program was
approved by the Board. The Nursing Models Incentive Reimbursement Program addresses the
nursing shortage and its underlying causes. The purpose of the program is to provide acute care
hospitals in New Jersey with an opportunity to develop innovative and cost-effective models
of nursing practice and nursing environments that will foster high-quality patient care. Seventy-
one hospitals filed applications to participate in the program. Awards totalling $7.1 million were
made by the Department of Health to 23 acute care hospitals in New Jersey. The Department
of Health intends to seek approval of the Hospital Rate-Setting Commission for awards for the
second year and it is expected that requests for proposals will be sent to New Jersey hospitals
in June.
2. Physician/Nurse Policymaking Committees. The Task Force recommended that the
Medical Society of New Jersey encourage hospitals to have a permanent voting or nonvoting
position on their medical staff executive committee; and that hospitals also be encouraged to
have a member of the medical staff executive committee as a permanent voting or nonvoting
member of the equivalent policymaking nursing committee. The recommendation was approved
by the Board of Trustees.
3. Concerns of Licensed Practical Nurse Association of New Jersey, Inc. The concept
of restricting the entry levels into nursing to associate and baccalaureate programs, as endorsed
by organized nursing, is of great concern to LPNs. The Task Force considered the request of
the LPN associate to support (a) the retention of the “Licensed Practical Nurse” title; and (b)
the present four entry levels of nursing. The Board approved the recommendation that the
Society endorse the educational mobility concept in nursing, i.e. from nursing assistant through
the various levels of nursing education.
4. Continuation of the Work of the Task Force. It was agreed by the members that the
work of the Task Force has not been completed. A number of items were suggested for possible
consideration at future meetings.
A. The main focus of the group has been on nursing; greater emphasis will be placed on
the shortage of allied health personnel.
B. While communication between physicians and nurses is a problem that has been con-
sidered, the Task Force believes it is still an area relevant to the shortage of nurses that needs
to be resolved and, therefore, will continue to explore the issue.
C. The establishment of nursing scholarships by the Medical Society of New Jersey or by
component societies has been touched on briefly and will be pursued at a future meeting.
Tr78
NEW JERSEY MEDICINE
New Business
Introduced by: Board of Trustees
Subject: Honorary Membership— George F. Willis
Whereas, George F. Willis has served for many years as executive director of the Bergen
County Medical Society; and
Whereas, he has been totally dedicated and devoted to the physicians of Bergen County
and the state of New Jersey; and
Whereas, he has shown committed service to MSNJ; now therefore be it
Resolved, that George F. Willis be elected an honorary member of the Medical Society
of New Jersey.
HOUSE ACTION: Adopted.
Introduced by: Frank Y. Watson, MD, Fellow
Subject: AMA Executive Vice-President
Whereas, the Executive Vice-President of the AMA, James H. Sammons, MD, announced
in December 1989 his intention to retire; and
Whereas, Doctor Sammons announced his retirement on February 9, 1990; and
Whereas, a sufficient period of time has elapsed for a thorough search for suitable candidates
to fill this position; and
Whereas, suitable outstanding candidates have applied for the position; now therefore be
it
Resolved, that the AMA Board of Trustees Search Committee cease its search without
further delay, evaluate the available candidates, and submit its recommendation to the AMA
Board of Trustees; and be it further
Resolved, that the AMA Board of Trustees fill the position of executive vice-president as
soon as possible and no later than the 1990 AMA Annual Meeting in June.
HOUSE ACTION: Adopted.
Introduced by: Suzanne A. Widrow, MD, Delegate, Morris County
Judith C. Gellrick, MD, Delegate, Bergen County
Subject: Gender Exploitation in the Workplace
Whereas, women make up about one third of the physicians in the state of New Jersey in
private practice and in academia; and
Whereas, the number of women in medicine in New Jersey continues to increase as more
women graduate from medical schools, and residency and fellowship programs; and
Whereas, it has been recognized that the professional rights of all physicians should be
protected and equal; and
Whereas, physicians who have equal training and credentials should have access to equal
pay, equal advancement, and equal promotion paths in academia and in private practice; now
therefore be it
Resolved, that the Medical Society of New Jersey is opposed to exploitation and discrimina-
tion in the workplace based on gender; and be it further
Resolved, that this resolution be forwarded to the AMA for action.
HOUSE ACTION: Adopted as amended by the House of Delegates.
NEW JERSEY MEDICINE
Tr79
Offices Filled By Election
1990 Annual Meeting
Office
Term
Nominee and County
Officer
President-Elect
1 year
Joseph A. Riggs, MD, Camden
1st Vice-President
1 year
William E. Ryan, MD, Mercer
2nd Vice-President
1 year
Joseph N. Micale, MD, Hudson
Trustees
1st District
3 years
Anthony P. Caggiano, Jr, MD, Essex
3 years
R. Gregory Sachs, MD, Union
2nd District
3 years
Philip J. Jasper, MD, Passaic
3 years
Carl Restivo, Jr, MD, Hudson
3rd District
3 years
Michael M. Heeg, MD, Mercer
3 years
Leticia V. DeCastro, MD, Middlesex
4th District
3 years
Angelo S. Agro, MD, Camden
Judicial Councilors
1st District
3 years
Anita Falla, MD, Essex
4th District
3 years
George T. Hare, MD, Camden
AMA Delegates
2 years
Karl T. Franzoni, MD, Mercer
2 years
Frederick W. Durham, MD, Camden
2 years
Ralph J. Fioretti, MD, Bergen
2 years
Palma E. Formica, MD, Middlesex
2 years
John S. Madara, MD, Salem
2 years
Henry J. Mineur, MD, Union
2 years
Edward A. Schauer, MD, Monmouth
AMA Alternate Delegates
1 year*
A. Ralph Kristeller, MD, Union
2 years
Joel S. Cherashore, MD, Essex
2 years
Paul J. Hirsch, MD, Somerset
2 years
A. Ralph Kristeller, MD, Union
2 years
Joseph N. Micale, MD, Hudson
2 years
Irving P. Ratner, MD, Burlington
Administrative Councils
2 years
Carl Restivo, Jr, MD, Hudson
Legislation
1st District
2 years
George J. Hill, MD, Essex
2nd District
2 years
Donald J. Cinotti, MD, Hudson
3rd District
2 years
Gabriel F. Sciallis, MD, Mercer
4th District
2 years
William V. Harrer, MD, Camden
Medical Services
1st District
2 years
Robert H. Stackpole, MD, Union
2nd District
2 years
Frederic E. Wien, MD, Passaic
3rd District
2 years
Ismail Kazem, MD, Mercer
4th District
2 years
Joseph W. Sokolowski, Jr, MD, Camden
*Vacancy created by resignation of Bernard Robins, MD.
Tr80
NEW JERSEY MEDICINE
Office
Term
Nominee and County
Mental Health
1st District
2nd District
4th District
5th District
2 years
2 years
2 years
2 years
Rita R. Newman, MD, Essex
Eva Muller, MD, Passaic
Kenneth J. Rubin, MD, Monmouth
Terry A. Johnston, MD, Atlantic
Public Health
1st District
2nd District
3rd District
4th District
2 years
2 years
2 years
2 years
Richard R. Lorber, MD, Union
John P. Mudry, MD, Bergen
Lawrence D. Frenkel, MD, Middlesex
Mary F. Campagnolo, MD, Burlington
Public Relations
1st District
3rd District
4th District
6th Member
2 years
2 years
2 years
2 years
Philip A. Rispoli, MD, Essex
Leticia V. DeCastro, MD, Middlesex
Aram M. Sarajian, MD, Ocean
Harry H. Brunt, Jr, MD, Monmouth
Standing Committees
Annual Meeting
2 years
2 years
John P. Mudry, MD, Bergen
Frank R. Romano, Sr, MD, Pinion
Finance and Budget
2 years
2 years
Julie M. Fortunato, MD, Bergen
Frank L. Redo, MD, Salem
Medical Education
2 years
2 years
Paul C. Royce, MD, Monmouth
Anthony P. DeSpirito, MD, Monmouth
Membership Services
2 years
2 years
Donald J. Cinotti, MD, Hudson
Robert L. Maggs, MD, Monmouth
Publication
2 years
2 years
William V. Harrer, MD, Camden
Morris Soled, MD, Hudson
NEW JERSEY MEDICINE
Tr81
SELLING YOUR PRACTICE?
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mation, contact:
Ruth DeFrino
201-376-2422
Schlott Realtors
Commercial Division
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FOR RENT OR SALE
Beautiful colonial office with full x-ray and lab in
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Call: Gale Wayman or Judy Bliss
215-295-8166
THE MEDICAL CENTER at JAMES STREET
MEDICAL CONDOMINIUM OFFICE BUILDING
IN MORRISTOWN, N.J.
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HOSPITAL.
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INCLUDING THREE BUSY PRIMARY CARE
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AMPLE PARKING WITH PUBLIC
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(extra parking available)
• Highly Visible Location
• Excellent Commuting Location
• Approximative 5400-5800 sq. feet
• 1990 Occupancy
For Information Call:
201-226-3769
674a
NEW JERSEY MEDICINE
MALPRACTICE SURCHARGE/SEPTEMBER HEARING
The regulation adopted by former Insurance Commissioner
Kenneth Merin is being legally contested by the Medical
Society of New Jersey. The proposal places a surcharge
of up to 5 percent on all malpractice policies for at
least seven years beginning with 1990. MSNJ is
represented by Judge Herbert Stern who will argue the
case before the appellate division in Trenton on
September 17, 1990. It is expected that the court will
render a decision within 30 to 60 days of trial.
PHYSICIAN ASSISTANTS HEARING: AUGUST 15, 1990
The State Board of Medical Examiners held a hearing on
August 15, 1990, on its regulatory proposal to authorize
physician assistants. State Senator John Bennett (Mon)
advised the Board that its proposal violates state law,
exceeds regulatory authority, and usurps legislative
prerogative. Judge Herbert Stern represented MSNJ and
concurred with Senator Bennett's opinion. In addition,
Judge Stern stated the proposal was unnecessarily vague
and inherently defective. Representatives of the State
Department of Corrections and the State Department of
Human Services testified in favor of the proposal but
offered no factual evidence regarding their methods to
recruit physicians for institutional purposes. A
thorough search of advertising in NEW JERSEY MEDICINE
for the last eight years indicated only one advertise-
ment was placed, asking interested psychiatrists to
contact a county corrections department; neither a
position description nor salary and benefit schedule
were included.
MSNJ OPPOSES NO-FAULT FEE SCHEDULE
On August 15, 1990, MSNJ submitted comments to the
insurance department in opposition to the proposed
automobile insurance PIP fee schedule. MSNJ maintains
that the automobile reform act known as FAIRA is
unconstitutional; that regardless of FAIRA, the fee
schedule is unconstitutional; that if FAIRA and the fee
schedule are constitutional, the fee schedule does not
comply with the statutory standard established in FAIRA.
Trial for the MSNJ lawsuit challenging FAIRA is expected
in late September.
PROFESSIONAL
LIABILITY
MD ENTITLED TO
PARTIAL IMMUNITY
The second physician agreed to come to the hospital after he was told
that the on-call surgeon was unavailable. When he arrived at the hospi-
tal, the patient was being taken from the emergency department to have
a CAT scan. He examined her and made the decision to operate while
she was in the CAT scan room. The patient was taken to the operating
room but was pronounced dead about 40 minutes later.
Her estate filed a malpractice action against the emergency department
physician and the treating physician. A trial court granted summary
judgment in favor of the treating physician on the grounds that he was
immune under the Good Samaritan statute.
Affirming the decision, the court said that the Good Samaritan statute
clearly applied to the physician’s activities in the hospital. The estate
argued that the statute should be applied in the “biblical” or “classic”
situation where the physician or other person rendered care outside his
job description or training. The court cited two other cases it had decided
earlier and said that the physician had no duty to respond to the emer-
gency situation.
The trial court properly denied the estate’s request to amend the com-
plaint to allege gross negligence and wilful and wanton misconduct.
(Reprinted with permission from The Citation, American Medical As-
sociation, Vol. 61, May 1, 1990)
A physician was entitled to partial immunity under the Good Samaritan
statute in an action for the death of an emergency department patient,
a Michigan appellate court ruled. On June 22, 1985, the patient was
admitted to the emergency department at a hospital after being injured
in an automobile accident. The emergency department physician exam-
ined the patient and determined that the situation required the services
of a surgeon. The on-call surgeon was unavailable because he was attend-
ing a wedding. The emergency physician then asked the unit secretary
to contact another physician.
RIGHT TO REFUSE A terminally ill pregnant patient had the right to determine the course
CESAREAN SECTION of medical treatment, including refusing a cesarean section that her
physicians believed was necessary to save the life of the fetus, the highest
court of the District of Columbia ruled. The 27-year-old patient had
suffered from cancer since the age of 13. She underwent major surgery
several times, together with multiple radiation treatments and
chemotherapy. She had married during a period of remission and soon
became pregnant. On June 9, 1987, when she was 25 weeks’ pregnant,
she went to the hospital for a scheduled visit. Because she was experienc-
ing pain in her back and shortness of breath, an x-ray was taken. This
revealed an apparently inoperable tumor that nearly filled her right lung.
She was admitted to the hospital and she said that she really wanted
to have her baby. Her condition worsened, and her physicians informed
her that her illness was terminal. She agreed to treatment designed to
extend her life until at least her 28th week of pregnancy because the
VOL. 87— NUMBER 9 SEPTEMBER 1990
685
PROFESSIONAL LIABILITY
potential outcome for the fetus was much better at 28 weeks.
The hospital filed an action for a declaratory judgment and the trial
court convened a hearing at the hospital. After hearing testimony, the
court found that the 26-1/2 weeks’ pregnant patient would probably die
within the next 24 to 48 hours and that the fetus was viable and had
a 50 to 60 percent chance to survive if a cesarean section was performed
as soon as possible. The court said that there was some testimony that
the operation may hasten the death of the patient and the delay would
greatly increase the risk to the fetus. The court noted that it did not i
know what the patient’s present views were because of sedation, but it
ordered that a cesarean section be performed to deliver the child.
The decision was relayed to the patient, who had regained consciousness.
She agreed to the procedure at first, but when a physician went back
to confirm her consent she clearly indicated that she did not want the
operation done. The court again ordered that a cesarean section be
performed.
The patient’s attorney obtained an immediate telephone appeal to the
highest court of the District of Columbia, but the three-judge panel
denied the motion for a stay of the operation. The operation took place
but the baby lived only a few hours, and the patient died of her cancer
two days later.
Following publication of the panel’s decision, the AMA, ACOG, and the
Medical Society of the District of Columbia filed an amicus brief arguing
that the court should not have interjected itself into the medical de-
cision-making process between the patient and her physicians. The
medical groups also reminded the court that the expressed wishes of a
patient as to treatment form an important part of a physician’s judgment
as to the appropriate course of medical care. On March 17, 1988, the
court granted rehearing en banc and vacated its earlier opinion and
judgment. The case was argued en banc September 22, 1988, and decided
April 26, 1990.
Recognizing that the situation may arise again because the hospital
operated a high-risk pregnancy clinic, the highest court of the District
of Columbia said that the trial court should have determined whether
the patient was competent to make her own medical decisions. The court
said that it was an error for the court to balance the rights of the patient
against the interests of the state until it had determined that the patient
had refused the procedure. If the patient were unable to make her own
judgment, the court must make a substituted judgment to determine
her subjective desires.
The court said that if the patient was competent, her informed decision
regarding the course of her medical treatment would control in virtually
all cases. The court anticipated that cases in which the patient’s wishes
must yield to a conflicting state interest will be extremely rare and truly
exceptional.
The court vacated the trial court’s orders and remanded the case for
proceedings that may be appropriate. The patient’s estate had filed a
civil action against the hospital based on the events leading to the trial
court’s order. The higher court stated that the trial court’s order allowing
the hospital to perform the cesarean section was presumptively valid
from the date it was entered until the day of the higher court’s ruling.
(Reprinted with permission from The Citation, American Medical As-
sociation, Vol. 61, June 1, 1990)
686
NEW JERSEY MEDICINE
MSNJ
NEWSLETTER
QUALITY OF LIFE AND
HEALTH SURVEY
The Citizens’ Committee on Biomedical Ethics is proud to announce its
participation in a two-state (Colorado and New Jersey) project funded
by PEW Charitable Trust. The project will measure citizens’ attitudes
about different aspects of quality of life. Quality of life is defined as
having three main areas: physical suffering and other symptoms; emo-
tions and outlook on life; and daily activities. The populations measured
include persons with chronic illness, disability, and recently diagnosed
lung cancer patients, and the medically underserved.
The study will reveal if health care services are worthwhile to those who
receive them; this information could be incorporated in a process for
developing practice guidelines or in the process used to set a list of
beneficial services. This research will lead to better public decisions in
personal and societal health care issues. In addition, the information
obtained will be used to develop a brief, generic, self-administered ques-
tionnaire for use in a wide variety of patient outcome studies.
The Committee is soliciting facilities, organizations, and associations to
help assess patient populations and, where appropriate, to assist in
administering a questionnaire developed over the past 18 months. Please
contact Theresa H. Hauber, MPH, Director, The Citizens’ Committee
on Biomedical Ethics, Inc., Oakes Outreach Center, 120 Morris Avenue,
Summit, NJ 07901-3948; 201/277-3858.
SPORTS ’90
On October 3, 1990, the Medical Society of New Jersey Committee on
Medical Aspects of Sports and the Academy of Medicine of New Jersey
are sponsoring a symposium entitled, “Sports ’90.” The day-long meet-
ing is open to physicians, nurses, coaches, school administrators, and
trainers. The conference, under the direction of Vincent J. Mclnerney,
MD, begins at 8:15 a.m. For further information on registration, call the
Medical Society of New Jersey headquarters at 609/896-1766.
NEUROPSYCHIATRIC
PROBLEMS IN
THE ELDERLY
UMDNJ-School of Osteopathic Medicine, Center for Aging, and the New
Jersey Geriatric Society are cosponsoring a one-day conference for pri-
mary care health providers on October 24, 1990, at the Harbor League
Club in Camden. The conference is entitled “Managing Neu-
ropsychiatric Problems in the Elderly.” In addition to lectures, there will
be four workshops. For further information, contact Marcella Freed, 609/
346-7083.
RELMAN RETIRES
AS EDITOR
The Massachusetts Medical Society (MMS) announced the retirement
of Arnold S. Reiman, MD, as editor-in-chief of The New England
Journal of Medicine in June 1991. Dr. Reiman was appointed editor in
1977 and became editor-in-chief in 1988. “After a long term of service
at the Journal, I feel it is time to devote myself more to writing and
teaching, and to participate more fully in public policy debates on
American health care,” said Dr. Reiman.
AIDS
WALKATHON
On Sunday, October 14, hundreds of people will walk through
Newark’s Branch Brook Park to benefit New Jersey women and children
living with AIDS. This event is sponsored by Champions-UMDNJ, the
VOL. 87— NUMBER 9 SEPTEMBER 1990
689
MSNJ NEWSLETTER
University’s nonprofit fundraising and advocacy group. Through gifts
from corporate donors as well as sponsors for individual walkers, Cham-
pions hopes to raise as much as $200,000 to establish an endowment fund
for University-wide AIDS-related projects. The first grant from the fund
will be awarded to Dr. Patricia Kloser, medical director of AIDS services
at UMDNJ-University Hospital, to support the specialized clinic for
women with AIDS.
STATE TO RETURN New Jersey is near settlement with the U.S. Department of Labor to
MILLIONS return $100 million, with interest, that the Kean administration trans-
ferred from New Jersey’s Unemployment Insurance Trust Fund last year
to a newly created Uncompensated Care Offset Account. The Offset
Account was established to help cover indigent health care costs in the
1989-1990 state budget. The transfer was challenged in federal court last
July by the AFL/CIO. The settlement would remove the threat of federal
decertification of the unemployment insurance program that would re-
sult in a loss of $37 million in administrative funding and more than
$1 billion in tax credits claimed by New Jersey employers. Under the
agreement, the state does not recognize an illegal transfer of funds and
agrees to return the money in 1992 or 1993.
MEDICARE PART B Blue Shield of Pennsylvania, the Medicare Part B carrier for New Jersey,
LATE CLAIMS announced that physicians and suppliers must file assigned Medicare
B claims within one year of the service date, or face a 10 percent payment
reduction. The penalty will be effective for services performed on or after
September 1, 1990. The payment reduction is a result of the Omnibus
Budget Reconciliation Act of 1989, that requires all physicians and
suppliers that accept assignment to file claims on behalf of Medicare
beneficiaries, and also for services performed after September 1, 1990.
PEDIATRIC AIDS Children’s Hospital of New Jersey and UMDNJ were awarded a $1.3
UNIT IN NEWARK million federal grant by the U.S. Department of Health and Human
Services to operate a pediatric AIDS resource center. The grant was
announced by U.S. Department of Human Services Secretary Louis
Sullivan and Senator Frank Lautenberg. Newark has the third largest
pediatric AIDS population in the nation and is fifth in the number of
adult AIDS cases.
The New Jersey Department of Health has determined that some hospi-
tals continued to bill a patient even after a valid charity care approval.
According to N.J.A.C. 8:3lB-4. 39(a) 10, a hospital cannot receive any
type of uncompensated care reimbursement if a charity care patient is
inappropriately billed. In cases where this situation is identified and
verified with the hospital, the appropriate place to report these amounts
is as courtesy adjustments. This treatment will be verified on audit.
HOSPITAL CEO Hospital CEO salaries and compensation were under scrutiny by the
SALARIES Newark Star-Ledger, apparently due to concerns about health care costs.
The recent newspaper article identified some New Jersey hospital CEOs,
their salaries, and the hospital’s gain or loss for the year reported. Their
report claimed a hospital’s size and the CEO’s salary are not related.
LICENSURE HHS Inspector General Richard Kusserow says that the state medical
BOARD licensing boards are overworked and understaffed, often with less than
five members per board. The inspector general indicates that the vol-
umes of red tape, the lack of sharing information, and poor legal proof
standards limit the boards’ decision-making abilities. He believes that
HHS should develop uniform performance indicators, distribute board
performance data, and create a national board.
HEALTH CARE FOR
THE UNINSURED
690
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
TOBACCO: TRADE
OR HEALTH
According to the General Accounting Office (GAO), the U.S. exported
$4.3 billion of tobacco in 1989. HHS Assistant Secretary for Health
James Mason, an advocate of banning the export of U.S. tobacco, recent-
ly had to cancel an appearance with U.S. trade representative officials,
proponents of tobacco exporting. HHS Secretary Sullivan, who has at-
tacked the use of tobacco in the home as well as the exporting of tobacco,
says that he is not ready to confront the exporting of tobacco head-to-
head, yet. The GAO indicated that Congress has to decide whether
health policy or trade policy will prevail.
1990 TRENDS IN
HEALTH CARE
According to an article in Hospital Management Review, the following
trends for the 1990s are expected: health care costs will increase 9 to
10 percent in 1990; hospital specific costs will increase 11 to 13 percent,
while insurance premiums increase 17 to 25 percent; the aging popu-
lation will create an inpatient surge and the increase in Medicare pa-
tients and governmental underfunding will strain hospital revenues;
ambulatory services will increase by 7 to 15 percent per year through
1993; the Harvard RVS scale will be implemented to set prices on
physician services; the nursing shortages will subside but it will cost
hospitals 7 to 20 percent in salary increases; utilization review groups
will become more aggressive with denial rates of 4 to 5 percent; 50
percent of the population will be enrolled in managed care plans; and
emergency room overcrowding will limit access to care.
ROOM/BOARD
RATES
According to Department of Labor statistics, increases in nursing
salaries, uncompensated care, and the demand for new advanced equip-
ment are forcing hospitals to continue to increase room and board rates.
With a 1.1 percent increase in March and a .7 percent increase in April,
the Department of Labor indicates that hospital room and board rates
are rising faster than physician fees.
NEW DRG
CATEGORIES
Next year, five diagnosis related group (DRG) categories will be added
to the current Medicare DRG listing: bone marrow treatment, HIV
treatment,' liver transplants, multiple trauma, and tracheotomies.
CAP DME
PAYMENTS
According to an ongoing General Accounting Office (GAO) study, Medi-
care payments vary widely across states for the same durable medical
equipment services. The variances are not supportable by differences in
supplier costs and are not viewed as reasonable. The GAO study results
prompted backing of the Administration’s 1991 budget proposal to cap
Medicare DME payments at national median levels.
EMPTY HOSPITAL
BEDS
According to a recent study conducted at Johns Hopkins University,
approximately 194,000 hospital beds or 21 percent of available staffed
beds are vacant. The study estimates the annual cost of maintaining
the unoccupied beds at $3.1 billion. The facilities experiencing the high-
est proportion of excess beds tended to be small, rural hospitals under
25 beds. The authors noted that elimination of these unoccupied beds
would not provide efficiencies since the capital investment already has
been made.
EMERGENCY ROOM
CRISIS
Representative Charles Rangel (D-NY) is spearheading a Congressional
caucus on the crises in U.S. emergency rooms. He has requested col-
leagues to study and visit emergency rooms and he has requested a
General Accounting Office review on emergency room quality. Factors
including uninsured patients, AIDS, drug abuse, staff shortages, and
violence have created overburdening and may require legislative action.
HMO ENROLLMENT
GROWS
Enrollment in traditional HMO plans grew 3.8 percent in 1989 according
to a report released by InterStudy, a Minnesota-based managed care
research firm. In January 1990, 33.1 million Americans were enrolled in
VOL. 87— NUMBER 9 SEPTEMBER 1990
691
MSNJ NEWSLETTER
HMO plans as compared to 31.9 million in January 1989. The number
of HMOs has declined with 15 of the nation’s 590 HMOs in July 1989
no longer in existence in January 1990. California leads the nation in
HMO enrollment rate with almost 30 percent of the state’s population
enrolled in an HMO.
According to a study of data from ten states regarding the quality and
necessity of ambulatory cataract surgery, endoscopy, and colonoscopy
procedures, the office of the inspector general (IG) concludes that Medi-
care still pays for unnecessary ambulatory surgical procedures. In 1988,
an estimated 6,400 cataract procedures and 23,600 endoscopies were
deemed unnecessary. In evaluating procedure quality during 1988, an
estimated 7,000 cases of poor quality care and 55,000 cases of question-
able quality care were noted. IG recommendations suggest intense
scrutiny and second opinion requirements for cataract surgery, as well
as preoperative review for endoscopies as a means of reducing unneces-
sary procedures.
A survey of over 1,700 hospital administrators and chief executive of-
ficers found that 71 percent of those responding believe health care in
individual cases should be limited because of cost. Over 50 percent of
the respondents believe that care for the elderly absorbs a dispropor-
tionate amount of available resources and that defensive medicine is not
an efficient use of available funds. Approximately 50 percent believe that
hospital closings in the next five years will total 330 to 550 of the
country’s 5,500 acute-care hospitals, including 43 percent who believe
their own facilities may close. Other survey findings include:
• Approximately 50 percent of hospital administrators and CEOs be-
lieve physicians are only moderately respected in the community, and
that physicians do not spend enough time with individual patients,
are overly concerned with making money, and do not satisfactorily
explain problems and treatments to patients.
• More than half the respondents indicated they would leave the health
care field if they could receive equal compensation.
• Twenty-five percent of those responding indicated that their facilities
had average occupancy rates less than 40 percent during the past year.
• Emergency room service was ranked as the most unprofitable service
by 58 percent and was followed by obstetrics at 46 percent. However,
hospital administrators and CEOs indicated that obstetrics (22 per-
cent) would be the service they would cut back, with clinics (16
percent), psychiatry (12 percent), ambulance services (12 percent),
kidney dialysis (11 percent) and neighborhood health centers (10
percent) suggested for cutbacks before emergency room service.
• The New England area received 23 percent of votes as the region of
the country with the best hospitals, while the east south central region
(Alabama, Kentucky, Tennessee, and Mississippi) received 35 percent
of the votes as the area having the worst hospitals.
Respondents believe more health care services will be provided outside
the hospital by the year 2000 and that there will be fewer, but larger,
regionalized hospitals providing short- and long-term care, hospital ad-
ministrators and CEOs believe that employers will be mandated to
provide a specific level of health insurance by the year 2000, and that
physicians and patients will have less freedom of choice.
FINI “Carrying your cares to bed is like sleeping with a pack on your back.”
HEALTH CARE
SURVEY
AMBULATORY
SURGERY
UNNECESSARY
692
NEW JERSEY MEDICINE
H EDITOR’S
DESK
Ms Gloria Steinem recently was interviewed on television on the occasion
of the republication of the magazine, Ms, after a hiatus of many months.
She said the original magazine had plenty of readers but had difficulty
in obtaining advertisers because of editorial policy. The new format will
exclude all advertising, and the costs of publication will be sustained
by subscriptions of $40 for six issues, in order to obtain editorial freedom.
According to Steinem, true editorial control means that her publisher
would not be expected to even see, let alone direct, the input to the
magazine.
Earlier this year, George D. Lundberg, MD, editor-in-chief of JAMA,
published his thoughts on restoring the proper balance between com-
mercialism and professionalism in medicine. He felt that the scale had
tipped too far toward medicine as a business and asked for a return to
loftier goals. He was not a lone voice crying out in the wilderness; many
others, including those mentioned in his bibliography, have written in
the same vein in recent years, some less delicately than Dr. Lundberg.
Nevertheless, the Illinois State Medical Society introduced a resolution
at the Annual Meeting of the AMA House of Delegates this past June
that would require Dr. Lundberg’s editorials to be scrutinized by an
overseeing committee before publication, in effect acting as a censor. The
resolution was defeated soundly.
We also are familiar with the policies of many other magazines, pe-
riodicals, and newspapers, as expressed in their editorials. Given a sub-
ject with political overtones, one can almost always predict the critique
to be offered by The New York Times, the Washington Post, the Na-
tional Review, and others. It is unnecessary to characterize remarks as
conservative, liberal, right-wing, or left-wing; battlelines have been
drawn and the readers know what to expect.
What are the responsibilities of the editor? How much fealty is due the
publisher as compared to the reader? Is the editor restricted to the
technical details of publishing a periodical? Et cetera, et cetera.
We have no quarrel with the leanings of reputable newspapers. Although
their editorials tend to be written in line with the sentiments of the
editorial staff and the publisher, all good newspapers will sound the
alarm on instances of malfeasance and corruption in high places, ir-
respective of party loyalty. We have witnessed this type of responsible
journalism many times (all too sadly) in recent years. As long as these
pro bono activities continue, we should welcome a “free press,” even
though sometimes it is our ox that is gored.
We certainly wish Steinem luck with her new endeavor. We are more
inclined to congratulate her on her magnificent salesmanship (sales-
personship?) to have a publisher underwrite the costs of the venture
without any say-so at all. Perhaps the publisher is Gloria’s alter-ego or,
at least, a J. P. Morgan descendant. The concept seems, at least from
the sketchy outline provided, to be marginal at best.
VOL. 87— NUMBER 9 SEPTEMBER 1990
695
EDITOR’S DESK
The disagreement between the Illinois State Medical Society and Dr.
George Lundberg touches much closer to home and this writer can place
himself in Dr. Lundberg’s shoes quite easily. Despite the volume dif-
ferences in many areas between JAMA and NEW JERSEY MEDICINE,
our respective publishers are the AMA and MSNJ. Our readership, with
additions, consists of physicians, most belonging to these organizations.
Neither George nor Howard believes an editor should confine himself
to encouraging the submission of manuscripts, proofreading, checking
layouts, making copy readable, and other similar necessities of publish-
ing. Some editorials will summarize or pinpoint articles in the journals.
Others can act as spurs — for thinking, reconsidering, or acting — some-
times in an effort to redress inequities in today’s unfair world. This
should evoke plaudits from the readers, even when the editor’s and the
reader’s perspectives and approaches may differ. (Arnold Reiman, MD,
apparently considers this aspect of editing as his mandate. He changed
from “editor” to “editor-in-chief’ to allow more time with policy and
philosophy and less with the necessary, more mundane efforts of publish-
ing a journal. And, he recently has announced that he will leave The
New England Journal of Medicine in June 1991 to devote more time to
writing, reading, and lecturing on topics dear to his heart.)
How closely should an editor of a scientific journal follow the policies
of the publisher, the sponsoring society(ies)? We cannot speak for Dr.
Lundberg, but this editor will parrot no organization and no individual,
although we may quote some at times. Rather, we will express personal
opinions that have been tempered by many years of participation in
organized medicine at all levels and therefore, more often than not, may
represent the views of MSNJ and most of its membership. If so, it will
be because of conviction and not caprice, because of logic and not blind
loyalty, and because of concern and not command.
“An editor is one who separates the wheat from the chaff and
prints the chaff. ”
Adlai Stevenson,
The Stevenson Wit (1966)
696
NEW JERSEY MEDICINE
n». .mi. n. BnHuwyiBiniuLm imuuimiiuiuiiBfflmB
BOOK
REVIEWS
CRANIOSPINAL Stephen Pomeranz, MD (ed). Philadelphia, PA, W.B. Saunders Com-
MAGNETIC RESONANCE pany, 1989. This text is a concise, organized discussion of central nervous
IMAGING system magnetic resonance imaging (MRI). The contributors admirably
perform the task of explaining the indepth physics of MRI as well as
reviewing MRI findings of neurologic diseases. The monograph begins
with a clear, thorough review of the physical basis of MRI scanning.
Special attention is given to flow and gradient-echo (GRASS/FLASH)
imaging. A discussion of the imaging parameters includes voxel size,
matrix size, TR, and TE.
The clinical sections start with a survey of normal anatomy. Pediatric
neurological diseases include the areas of congenital anomalies and
neoplasms. Adult diseases range from neoplasms and trauma, including
hemorrhage, to white matter disease and spinal disorders.
The text is well written but the scans are of fair-to-good quality. The
major shortcoming of this book is that it was written before the introduc-
tion of intravenous (IV) contrast, gadolinium, which has changed the
manner many diseases, especially neoplasms, are evaluated. However,
the volume still deserves a place in the physician’s library as an excellent
review of physics and an evaluation of diseases that would not need IV
contrast MRI. □ Neil B. Horner, MD
E. David Crawford, MD, and Sakti Das, MBBS. Philadelphia, PA, Lea
and Febiger, 1990. I love a surgical textbook with big, beautiful illustra-
tions teaching physicians how to do complicated operations that are not
often performed. Many physicians do not have the opportunities to
perform cystectomies or radical prostatectomies, to say nothing of vari-
ous forms of continent urinary diversion. It is helpful to have a few how-
to suggestions from those physicians with experience. This book is a
compilation of articles by many outstanding urologists. It is a very good
and useful book for urologists who are going to tackle these procedures
from time to time, with trepidation. □ Robert Zufall, MD
PETAL A NEONATAL Walker A. Long, MD. W.B. Saunders Company, Philadelphia, PA, 1990.
0APQIQLQQY This encyclopedic, multiauthored book attempts to fill an enormous void
in contemporary medicine — the rapidly expanding field of perinatal
cardiology — and succeeds admirably. If not already, it soon will be the
classic reference text for this ultraspecialty. It is not easy reading; even
cursory perusal requires extreme diligence especially for the
nonresearcher, pedestrian cardiologist. Unusual features include ex-
tensive illustrations designed “to inform and delight the reader,” vol-
uminous references (the chapter on pulmonary hypertension of the new-
born has 335 notations), and “historical perspectives” at the beginning
of each chapter that represent “extensive sleuthing” to identify the first
discoverer of a disorder or procedure.
Part one is a rigorous analysis of current thinking in developmental
structure and function gleaned primarily from the laboratories of schol-
arly “young turks.” I agree with Dr. Long that clinicians not familiar
CURRENT
GENITOURINARY
CANCER SURGERY
VOL. 87— NUMBER 9 SEPTEMBER 1990
699
BOOK REVIEWS
with this information “put themselves and their patients at a disadvan-
tage”; yet, many may be unable or unwilling to expend the effort neces-
sary to digest this material.
Part two deals with the exploding field of fetal cardiology. It includes
excellent chapters on genetics, maternal problems affecting the fetus,
fetal electrocardiography, and echocardiography as well as diagnosis and
management of important cardiac problems.
Part three is an exhaustive study of neonatal cardiology, and, for me,
is the highlight of the book. It is divided into four sections describing
diagnostic modalities, cardiovascular disorders of the preterm and the
term neonate, and therapeutic modalities (medical, interventional, and
surgical). The only criticism I can offer is that like most other multi-
authored texts, this one suffers from certain imbalances. For example,
the chapter on blood gases is nearly twice as long as that on clinical
examination. Further, the discussions of electrocardiography,
echocardiography, cardiac catheterization, and teratogenic agents are
skimpy, while those concerning anesthesia for neonatal cardiac surgery
and persistent pulmonary hypertension of the newborn are ponderous.
On the other hand, the information and illustrations contained in total
anomalous pulmonary venous drainage and chest radiography (plain
films only) deserve honorable mention. A very special review of post-
operative intensive care is saved for last. In addition to a thorough
scientific and clinical analysis, Denfield and Henry close with a poignant
plan for dealing with family, community, hospital staff, and physician
when a neonate with congenital heart disease dies.
I recommend this book to neonatalogists, pediatricians, pediatric
cardiologists, and surgeons with the caveat that appreciation of its con-
tent will be a demanding but rewarding task. □ Edwin L. Rothfeld, MD
OSTEOPOROSIS John F. Aloia, MD. Leisure Press, Champaign, IL, 1989. This book,
intended for health care professionals, is an excellent review of the topic
covering all areas: definition, anatomy and physiology, risk factors,
prevention, and treatment. The text is not intended for specialists in
the field; it is not too basic to be of use to the family practitioner as
a review of the subject.
The chapters on rehabilitation and exercise for the patient with this
disorder are informative for the physician as they generally are not
included in medical literature on the subject. The chapter on nutrition
is another phase of the subject probably not familiar to many physicians
in any detail, as this generally is delegated to the dietary service. I feel
this book is recommended reading for anyone interested in osteoporosis.
□ Christine E. Haycock, MD
PHYSICAL ACTIVITY Waneen W. Spirduso (ed). Human Kinetics Books, Champaign, IL,
AND AGING 1989. This book is a compilation of papers from presentations given at
the American Academy of Physical Education meeting in 1988. Written
bv investigators thoroughly knowledgeable in this area, it is a collection
well worth reading for any physician interested in geriatrics. The papers
on physical activity in the elderly, and on exercise prescriptions for them
will be particularly informative to the physician who does not normally
deal with these topics. The physica1 psychological, and physiological
changes occurring with aging are well covered and informative. The
papers generally are well written, referenced, and illustrated as required.
I recommend the book to all physicians for general reading. □ Christine
E. Haycock, MD
700
NEW JERSEY MEDICINE
Pediatric Cancer
Mortality Rates
in New Jersey and the United States
DONA SCHNEIDER, PhD
MICHAEL R. GREENBERG, PhD
BONNIE STACH, MCRP
The authors studied pediatric mortality rates for four major categories of
neoplasms for the years 1950 to 1985. This report indicates differences in
trends between the rates of the New Jersey population and of the United
States population, for males and females, and whites and nonwhites.
Published more than a decade ago by the Na-
tional Cancer Institute, the Atlas of Cancer
Mortality for U.S. Counties 1950-1969 drew
attention to major differences in the regional dis-
tribution of cancer deaths. After adjusting for dif-
ferences in age, race, and sex, the Atlas indicated
some regions had 50 percent higher rates than
others.1 Recent time series studies have shown the
differences in cancer mortality among states to be
From Rutgers, The State University of New Jersey, New
Brunswick, Drs. Schneider and Greenberg are affiliated
with the Department of Urban Studies and Community
Health and Ms. Stach is affiliated with the Department
of Urban Planning. The manuscript was submitted in
November 1989 and accepted in March 1990. Requests
for reprints may be addressed to Dr. Schneider, Rutgers
University, Department of Urban Studies and Community
Health, Lucy Stone Hall, New Brunswick, NJ 08903.
decreasing.23 Reasons offered to explain this con-
vergence of rates include urbanization of formerly
rural areas, increasing homogeneity of culture, inter-
regional migration, better reporting and accuracy of
incidence and mortality data in formerly rural areas,
and the declining importance of European-born
Americans and their cultural habits.
New Jersey is a sentinel state for national cancer
trends. The Atlas showed that New Jersey exhibited
the highest white male overall cancer mortality rate
in the United States and the second highest white
female rate. The Atlas and other studies showed
relatively high cancer mortality rates for respiratory,
digestive, and urinary tract cancers for the male and
female white subpopulations in the New Jersey
metropolitan corridor.45 Yet, recent research shows
rapid decline of age-adjusted rates in New Jersey
compared to the remainder of the United States,
VOL. 87— NUMBER 9 SEPTEMBER 1990
703
Table 1. Pediatric mortality for malignant neoplasms, 1950-1985.
Population Characteristics New Jersey United States
95 Percent
Confidence Interval Age'
Year Race
Sex
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Lower
Limit
Upper
Limit
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Adjusted
Rate
Index
(NJ/US)
Total, 0-24 Years of age
1926
9.14
8.80
9.51
58515
8.18
1.12
1950- White
Male
1022
10.64
10.25
11.06
30089
9.61
1.11
1959
Female
756
7.88
7.33
8.47
22662
7.22
1.09
Nonwhite
Male
79
8.36
6.66
10.45
3126
7.31
1.14
Female
69
7.44
5.94
9.45
2638
5.94
1.25
Total, 0-24 Years of age
1839
8.36
8.05
8.69
52095
7.55
1.11
1960-1961 White
Male
940
9.77
9.15
10.41
26832
9.03
1.08
1964-1969
Female
718
7.37
6.85
7.94
19464
6.53
1.13
Nonwhite
Male
93
7.17
5.82
8.82
3161
6.83
1.05
Female
88
6.57
5.30
8.15
2638
5.47
1.20
Total, 0-24 Years of age
1887
6.44
6.20
6.69
56241
6.09
1.06
1970- White
Male
983
8.02
7.52
8.54
28919
7.50
1.07
1979
Female
649
5.37
4.97
5.80
19433
5.14
1.05
Nonwhite
Male
151
6.28
5.34
7.39
4270
5.43
1.16
Female
104
4.07
3.34
4.97
3380
4.23
0.96
Total, 0-24 Years of age
871
5.28
4.94
5.64
26474
4.78
1.10
1980- White
Male
403
6.06
5.49
6.69
13129
5.77
1.05
1985
Female
320
4.95
4.43
5.53
8979
4.09
1.21
Nonwhite
Male
78
4.58
3.82
5.73
2462
4.61
0.99
Female
70
4.13
3.24
5.25
1904
3.57
1.16
especially among middle-aged populations. In other
words, cancer mortality rates are converging be-
tween New Jersey and the United States.35
Is New Jersey also a sentinel state for pediatric
cancer? Are New Jersey’s pediatric rates converging
with the United States? To answer these questions,
the authors are researching the cancer incidence
data that became available in 1979, the year the
New Jersey Cancer Registry began collecting infor-
mation. To gain a perspective of what has happened
in pediatric cancer in New Jersey and the United
States over time, it is necessary to use mortality
data. The authors present an analysis of mortality
data as historical background and identify possible
future incidence-based cancer studies.
DATA AND METHODS
Data. Cancer mortality counts for New Jersey and
the United States for 1950 to 1985 were obtained
from the United States Department of Health and
Human Services’ annual publication of mortality
statistics.6 As death certificates are repatriated to
reflect state of residence, all cases of New Jersey
residents that died out of state were included in the
analysis. [This repatriation answers the problem of
New Jersey cases treated in Philadelphia and New
York, a major draw of cancer patients to regional
cancer centers over the 36-year period.]
In order to study pediatric age groups, the mor-
talities were aggregated into the following three age
categories: 0 to 4, 5 to 14, and 15 to 24. These
categories represent aggregates of standard five-year
age groupings reported by vital statistics. Deaths in
the 19-to-24-year age group were included as they
were likely to have been diagnosed before age 19, a
routine pediatric age cutoff point.
704
NEW JERSEY MEDICINE
Table 2. Pediatric mortality for leukemia and aleukemia, 1950-1985.
Population Characteristics New Jersey United States
95 Percent
Confidence Interval Age'
Year Race
Sex
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Lower
Limit
Upper
Limit
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Adjusted
Rate
Index
(NJ/US)
Total, 0-24 Years of age
772
3.32
3.09
3.57
22698
2.92
1.14
1950- White
Male
426
4.01
3.64
4.42
11841
3.48
1.15
1959
Female
296
2.79
2.49
3.13
9138
2.68
1.04
Nonwhite
Male
30
2.98
2.01
4.26
965
2.07
1.44
Female
20
1.87
1.14
2.88
754
1.53
1.22
Total, 0-24 Years of age
687
2.87
2.66
3.10
20431
2.79
1.03
1960-1961 White
Male
347
3.29
2.96
3.65
10775
3.41
0.97
1964-1969
Female
284
2.70
2.40
3.04
7811
2.49
1.08
Nonwhite
Male
33
2.40
1.65
3.38
1082
2.24
1.08
Female
23
1.61
1.02
2.42
763
1.48
1.09
Total, 0-24 Years of age
683
2.25
2.09
2.43
19508
2.07
1.09
1970- White
Male
352
2.78
2.50
3.09
10114
2.56
1.09
1979
Female
244
1.96
1.72
2.23
7092
1.84
1.06
Nonwhite
Male
54
2.13
1.60
2.79
1359
1.68
1.27
Female
33
1.19
0.82
1.68
943
1.15
1.03
Total, 0-24 Years of age
273
1.65
1.46
2.10
8446
1.52
1.09
1980- White
Male
124
1.86
1.55
2.23
4278
1.88
0.99
1985
Female
100
1.55
1.27
1.89
2867
1.31
1.18
Nonwhite
Male
19
1.11
0.67
1.73
772
1.43
0.78
Female
30
1.75
1.18
2.50
529
0.98
1.79
The aggregate age groups were broken down by sex
and race: white male, white female, nonwhite male,
and nonwhite female. Nonwhite data were an ag-
gregate of black, Asian, American Indian, and all
other racial groups not considered purely white.
Both United States and New Jersey data were re-
ported in the same manner during these periods.
Data were placed into the following four
categories: all malignant neoplasms (ICD-0
800-999), leukemia and aleukemia (ICD-0 980-994),
lymphosarcoma and related neoplasms (ICD-0
959-969), and all other malignant neoplasms (all
cancers minus leukemia and aleukemia, lympho-
sarcoma, and related neoplasms). While the use of
the terms aleukemia (leukemia cases presenting
with normal or low white blood counts) and lympho-
sarcoma are archaic, these terms are used by gov-
ernmental reporting sources and provide consistency
of reporting throughout the entire 36-year time
period. The categories were chosen as likely to yield
the most information on pediatric cancer mortality,
and were aggregated in order to yield sufficient cases
for analysis. Deaths from other important pediatric
cancers in this report are included in the “all other”
category.
The pediatric age, sex, and race cancer mortality
data for New Jersey and the United States then were
aggregated into four time periods: 1950 to 1959, 1960
to 1969, 1970 to 1979, and 1980 to 1985. As New
Jersey did not collect racial data for 1962 and 1963,
these two years were omitted from the analysis for
both New Jersey and the United States; the 1960 to
1969 block, then, represents only eight years.
In 1979, mortality data published by the United
States Department of Health and Human Services
was broken down further into the following racial
VOL. 87— NUMBER 9 SEPTEMBER 1990
705
Table 3. Pediatric mortality for lymphosarcoma and related neoplasms, 1950-1985.
Population Characteristics
Year Race Sex
New Jersey
United
States
Age-
Adjusted
Rate
Index
(NJ/US)
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
95 Percent
Confidence Interval
Lower Upper
Limit Limit
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Total, 0-24 Years of age
259
1.44
1.27
1.63
7621
1.20
1.20
1950- White
Male
145
1.77
1.50
2.09
4492
1.61
1.10
1959
Female
92
1.14
0.93
1.41
2404
0.87
1.30
Nonwhite
Male
13
1.58
0.84
2.70
457
1.19
1.33
Female
9
1.12
0.51
2.13
268
0.64
1.74
Total, 0-24 Years of age
285
1.51
1.34
1.70
7569
1.22
1.24
1960-1961 White
Male
162
1.94
1.66
2.27
4472
1.65
1.17
1964-1969
Female
101
1.25
1.02
1.53
2288
0.88
1.43
Nonwhite
Male
16
1.31
0.75
2.12
486
1.14
1.15
Female
6
0.55
0.20
1.20
292
0.66
0.84
Total, 0-24 Years of age
258
0.93
0.82
1.05
7545
0.84
1.10
1970- White
Male
137
1.16
0.98
1.38
4414
1.17
1.00
1979
Female
77
0.68
0.54
0.85
2194
0.60
1.14
Nonwhite
Male
25
1.05
0.68
1.55
610
0.80
1.30
Female
19
0.81
0.49
1.26
327
0.43
1.90
Total, 0-24 Years of age
142
0.87
0.74
1.03
3304
0.60
1.45
1980- White
Male
83
1.26
1.01
1.58
1853
0.82
1.54
1985
Female
42
0.65
0.47
0.89
971
0.44
1.48
Nonwhite
Male
12
0.71
0.37
1.24
308
0.60
1.18
Female
5
0.31
0.10
0.72
172
0.33
0.94
groups: white, nonwhite, and black. The new black
component of the data represents a subgroup of the
nonwhite category. State data, as well as national
data, were reported in this manner.
In order to make comparisons of age-adjusted
rates among the black population, mortality data
were grouped by sex and race in the following man-
ner for 1979 to 1985: white male, white female,
nonwhite male, nonwhite female, black male, and
black female. The age groups remained the same.
Methods. The methodological approach was to
compute and to compare cancer mortality rates for
New Jersey and the United States. The mortality
counts were divided by the numbers of residents in
each age, sex, and racial group, yielding age-specific
rates. The resident population, or the population-at-
risk figures for the years 1950 to 1980, were obtained
from United States Bureau of the Census decennial
census counts and from the Bureau’s 1988 revision
of population estimates for the years 1981 to 1987.
[The Bureau’s figures for the study years 1981 to
1985 are estimates; the authors question the ac-
curacy of the population-at-risk data for those years;
nonetheless, we follow the convention of using them
for these studies.3,6]
The direct method of calculating age-adjusted
rates was used to mathematically control for age
differences between the population of New Jersey
and that of the United States. This allows New Jer-
sey’s rates to be compared to other states. The 1980
population of the United States was used as the
population standard for the age-adjusting process.
Confidence limits were calculated for the New Jersey
age-adjusted rates using the method of Chiang and
are presented along with the data in tabular form.7
Data are presented in tabular and graphical for-
706
NEW JERSEY MEDICINE
Table 4. Pediatric mortality for all other neoplasms, 1950-1985.
Population Characteristics
New Jersey
United States
95 Percent
Confidence Interval
Age-
Year Race
Sex
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Lower
Limit
Upper
Limit
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Adjusted
Rate
Index
(NJ/US)
Total, 0-24 Years
of age
895
4.38
4.10
4.68
28196
4.07
1.08
1950- White
Male
451
4.86
4.43
5.34
13756
4.53
1.07
1959
Female
368
3.95
3.56
4.38
11120
3.66
1.08
Nonwhite
Male
36
3.80
2.66
5.26
1704
4.05
0.94
Female
40
4.45
3.18
6.05
1616
3.76
1.18
Total, 0-24 Years
of age
867
3.98
3.72
4.26
24095
3.54
1.12
1960-1961 White
Male
431
4.55
4.14
5.01
11585
3.97
1.15
1964-1969
Female
333
3.42
3.07
3.81
9365
3.17
1.08
Nonwhite
Male
44
3.45
2.50
4.64
1593
3.45
1.00
Female
59
4.41
3.38
5.74
1583
3.34
1.32
Total, 0-24 Years
of age
946
3.26
3.06
3.48
29188
3.19
1.02
1970- White
Male
494
4.08
3.73
4.46
14391
3.78
1.08
1979
Female
328
2.73
2.45
3.05
10147
2.69
1.01
Nonwhite
Male
72
3.10
2.80
3.44
2301
2.95
1.05
Female
52
2.07
1.55
2.72
2110
2.65
0.78
Total, 0-24 Years
of age
456
2.76
2.52
3.03
14724
2.65
1.04
1980- White
Male
196
2.94
2.55
3.39
6998
3.07
0.96
1985
Female
178
2.75
2.37
3.19
5141
2.34
1.18
Nonwhite
Male
47
2.76
2.03
3.68
1382
2.59
1.06
Female
35
2.07
1.44
2.88
1203
2.26
0.92
mats. Tables present New Jersey pediatric deaths
and pediatric mortality rates in cancer deaths/
100,000 population-at-risk compared to United
States rates for the aggregate 0-to-24-year age group,
by race, sex, and select cancers. For the ease of the
reader, ratios appear in the Tables as the age-ad-
justed rate index. This index is the New Jersey rate
divided by the United States rate. An index of 1.0
indicates that both New Jersey and the United
States had the same rate. An index greater than 1.0
indicates that the New Jersey rate is higher; less
than 1.0 indicates that New Jersey’s rate is lower.
By comparing the index over time, trends can be
observed. For instance, Table 1 presents pediatric
mortality data for all malignant neoplasms. For
white males, the index is 1.11 for the period 1950 to
1959, 1.08 for the period 1960 to 1969, 1.07 for the
period 1970 to 1979, and 1.05 for the period 1980 to
1985. The ratio shows that mortality for white males
for all malignant neoplasms, then, is decreasing and
converging with that of the United States rate.
Table 2 presents the pediatric mortality data for
leukemia and aleukemia. Table 3 presents data for
lymphosarcoma and related neoplasms. Table 4 is
mathematically derived and represents all other
neoplasms, i.e. those not covered by Tables 2 and
3. Table 5 lists pediatric cancer mortality data for
the aggregate years 1979 to 1985 for blacks by sex
and major cancer type. Table 5 displays the first
available data on blacks as a subset of the nonwhite
racial grouping; the data are important because they
are race specific, even with the small number of
deaths.
Selected data are presented graphically, depend-
ing on data reliability and suitability for presen-
tation. For instance, the large number of white pa-
VOL. 87— NUMBER 9 SEPTEMBER 1990
707
Table 5. Black pediatric cancer mortality data, 1979-1985.
New .
Jersey
United
States
Race
Sex
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
95 Percent
Confidence Interval
Lower Upper
Limit Limit
Total
Deaths
(0-24)
Age-
Adjusted
Rate
(0-24)
Age-
Adjusted
Rate
Index
(NJ/US)
Total, 0-24
Years of age
1038
5.36
5.16
5.58
31301
4.84
1.11
All
Pediatric
Malignant
Black
Male
79
4.99
3.98
6.23
2443
5.34
0.93
Neoplasms
Female
78
4.86
3.87
6.08
1943
4.17
1.17
Total, 0-24 Years of age
328
1.69
1.51
1.88
10085
1.55
1.09
Leukemia
and
Black
Male
18
1.12
0.66
1.77
744
1.60
0.70
Aleukemia
Female
32
1.98
1.36
2.79
528
1.12
1.77
Total, 0-24
Years of age
161
0.84
0.72
0.99
3883
0.61
1.38
Lymphosarcoma
and
Related
Black
Male
12
0.79
0.41
1.38
319
0.72
1.10
Neoplasms
Female
4
0.25
0.07
0.64
168
0.37
0.69
Total, 0-24
Years of age
549
3.67
3.37
4.76
17333
3.28
1.12
All
Other
Black
Male
49
3.08
2.28
4.08
1380
3.01
1.02
Neoplasms
Female
42
3.41
2.46
4.61
1247
3.28
1.04
tients and the resultant small confidence limits
make these data both reliable and suitable. Tables
1 through 5 show confidence limits for our sample.
No confidence limits are provided for the United
States data as they represent the total population.
Nonwhite cases have significant numbers of cases,
but the category is so racially nonspecific it is hard
to draw firm conclusions. Black data are racially
specific, but the numbers of cases are small and the
confidence limits so large that graphical presen-
tation is ineffective.
RESULTS
Data in Table 1 and Figure 1 show that all four
New Jersey subpopulations had higher pediatric
cancer mortality rates than the United States in the
period 1950 to 1959. These rates declined over time,
although not at the same rate for all sex and racial
groups or for all types of cancer.
White male rates fell from 10.64/100,000 in 1950
to 1959 to 6.06/100,000 in 1980 to 1985, and the age-
adjusted rate index declined from 1.11 to 1.05. The
95 percent confidence bands for the white male New
Jersey rate for 1980 to 1985 include the United States
rate. White female rates declined from 7.88 to 4.95.
The age-adjusted rate index ratio for this group de-
creased from 1.09 in 1950 to 1959 to 1.05 during 1970
to 1979, yet it increased to 1.21 in 1980 to 1985.
Consequently, the white female rates do not follow
the expected converging pattern.
Nonwhite male rates in New Jersey decreased
from 8.36 to 4.58 and the age-adjusted rate index
ratio decreased from 1.14 to 0.99 from 1950 to 1959
to 1980 to 1985. For nonwhite females, the rates
decreased from 7.44 to 4.13, and the age-adjusted
rate index ratio decreased from 1.25 to 1.16. The 95
percent confidence bands for both the New Jersey
nonwhite male and nonwhite female rates include
the United States rates. In other words, pediatric
cancer mortality in New Jersey and United States
nonwhite subgroups follow the expected convergent
pattern.
The data indicate the different pediatric mortality
rates of subpopulations for the category all malig-
nant neoplasms. In order to look at this phenomenon
more closely, we disaggregated the data into three
708
NEW JERSEY MEDICINE
Age-adjusted rates
Figure 1. Pediatric mortality for malignant neoplasms.
major subgroupings of childhood cancer: leukemia
and aleukemia, lymphosarcoma and related neo-
plasms, and all other pediatric cancers; Tables 2, 3,
and 4 and Figures 2 and 3 present these findings.
Table 2 lists the data for pediatric mortality from
leukemia and aleukemia. A graphical presentation
of all cases and white data is presented in Figure 2.
Pediatric mortality from this disease category de-
creased during the study period for all four sub-
populations.
Table 2 shows United States age-adjusted mor-
tality rates for leukemia and aleukemia to have the
largest decrease for white males (from 3.48 to 1.88),
and the smallest decrease for nonwhite females (1.53
to 0.98). The New Jersey data show the same pat-
tern, again with the largest decrease for white males
(from 4.01 to 1.86) and the smallest decrease for
nonwhite females (1.87 to 1.75).
The age-adjusted ratio data showed that all four
New Jersey subpopulations started out with higher
rates than the United States subpopulation, in the
1950 to 1959 period, but that white male and
nonwhite male rates rapidly converged. Female
white and nonwhite ratios fluctuate and reverse
their downward trend in the 1980 to 1985 period. Of
all the subgroups, however, only New Jersey
nonwhite females in 1980 to 1985 have an age-ad-
justed mortality rate with confidence bands that do
not include the United States rate. Overall, male
leukemia and aleukemia generally follow the ex-
pected pattern of convergence with United States
rates, but female rates do not converge.
Table 3 presents the data on pediatric mortality
from lymphosarcoma and related neoplasms. Due to
data collections methods during the early years of
the study period, it is not possible to distinguish
VOL. 87— NUMBER 9 SEPTEMBER 1990
709
Age-adjusted rates
Hodgkin’s disease from non-Hodgkin’s lymphoma.
This is a serious drawback, as the prognosis for these
diseases is very different, with Hodgkin’s disease
having a lower mortality rate.89
The age-adjusted mortality rates for all four sub-
populations for lymphosarcoma and related neo-
plasms began significantly higher for New Jersey
pediatric patients in the 1950 to 1959 period. The
data show that the rates fall substantially for all four
subgroups, with the largest decrease for New Jersey
residents among nonwhite males (1.58 to 0.71) and
the smallest decrease among white females (1.14 to
0.65).
White male and white female rates diverged from
the United States rate for lymphosarcoma and re-
lated neoplasms in 1960 to 1969, converged during
1970 to 1979, and diverged again by 1980 to 1985.
Nonwhite rates seem to converge, although the rela-
5 -
1
1950-1959
1960-1969
1970-1979
1980-1985
US
2.92
2.79
2.07
1.52
New Jersey
3.32
2.87
2.25
1.65
All cases
Figure 2. Pediatric mortality for leukemia and
aleukemia.
Age-adjusted rates
White males
U. 1
1950-1959
1960-1969
1970-1979
1980-1985
us
0.87
0.88
0.6
0.44
New Jersey
1.14
1.25
0.68
0.65
White females
5 -
4
3
2
US
New Jersey
U. 1
1950-1959
1960-1969
1970-1979
1980-1985
us
1.2
1.22
0.84
0.6
New Jersey
1.44
1.51
0.93
0.87
All cases
Figure 3. Pediatric mortality lymphosarcoma and related neoplasms.
710
NEW JERSEY MEDICINE
tive increase during 1970 to 1979 and the small
number of cases suggests a cautious reaction to this
conclusion. Hence, the data for this disease category,
are not consistent with the expected pattern of con-
vergence with United States rates.
Table 4 presents the data on the remainder of
deaths from malignant neoplasms, i.e. total pedi-
atric cancer deaths minus those from leukemia and
aleukemia and lymposarcomas and related
neoplasms. Rates clearly fall, especially among
nonwhite females (4.45 to 2.07) and least among
nonwhite males (3.80 to 2.76). The data show that
for the category of all other neoplasms, New Jersey’s
subpopulations, except for nonwhite males, started
out with higher rates than the United States in the
1950 to 1959 period. Rates for white males, non white
males, and nonwhite females converged with na-
tional rates by 1980 to 1985, but white female rates
did not converge.
Table 5 gives an aggregate of black pediatric
cancer mortality data for the years 1979 to 1985.
These data are offered as they are the only data
available that are subset by the racial category black
rather than the nonspecific category nonwhite.
Black data account for the majority of cases in the
nonwhite category in this time period, but this
should not be extrapolated backward to encompass
earlier time periods when specific racial data were
not gathered.
With the caveat that the 1979 to 1985 aggregate
data are difficult to interpret due to the small
numbers of cases, New Jersey’s black male rates are
lower than their United States counterparts, and
black female rates are higher than their United
States counterparts. The number of cases for both
sexes is so small that the New Jersey rates fall within
the 95 percent confidence bands for the United
States rates.
CONCLUSION
The rates for all major cancer groups for all sub-
populations in New Jersey and the United States fell
during the 36-year study period. Data clearly show
that New Jersey had higher rates than the United
States for pediatric cancer mortality for all races and
genders from 1950 to 1959. Although New Jersey
rates have converged with United States rates for
some subpopulations for leukemias and all other
pediatric cancers, rates remain higher for white
females and the category lymphosarcomas. The
question remains as to why this phenomenon exists.
Given the inconsistent trends among cancer types
and subpopulations, additional epidemiologic re-
search is necessary. Incidence and mortality data for
specific pediatric cancers, especially those with con-
verging and diverging rates, i.e. leukemia and
lymphosarcoma, should be compared. Another ap-
proach is to compare the populations contracting
lymphosarcoma in both New Jersey and other states.
Comparison of differences in state reporting systems
offers a third avenue to explore. A strong cancer
incidence data set is critical to these efforts. ■
REFERENCES
1. Mason T, McKay F, Hoover R, et al . : Atlas of Cancer
Mortality for U.S. Counties, 1950-1969. Washington, DC,
DHEW Pub. No. NIH 75-780, 1975.
2. Riggan W, Van Bruggen J, Acquavella J, et al.: U.S.
Cancer Mortality Rates and Trends, 1950-1979, 4 Vol-
umes. Washington, DC, Superintendent of Documents,
EPA/600/l-83/015e, 1983 and 1987.
3. Greenberg MR: Urbanization and Cancer Mortality.
New York, NY, Oxford University Press, 1983.
4. Greenberg MR, Caruana J, Holcomb B, et al.: High
cancer mortality rates from childhood leukemia and young
adult Hodgkin’s disease and lymphoma in the New Jersey-
New York-Philadelphia metropolitan corridor, 1950-1969.
Cancer Research 40:439-443, 1980.
5. Greenberg M: Death rates in New Jersey. NJ MED
85:950-953, 1988.
6. US Bureau of the Census: US Population Intercensal
Estimates Methodology. Current Population Reports.
Series P-23, Number 103 and 158. Washington, DC.
7. Chiang CL: Standard error of the age-adjusted death
rate. Vital Statistics 47:275-285, 1961.
8. Young JL, Ries LG, Silverberg E, et al.: Cancer in-
cidence, survival, and mortality for children younger than
age 15 years. Cancer 58:598-602, 1986.
9. Li FP, Bader JL: Epidemiology of cancer in child-
hood, in Oski FA, Naiman L, in Hematology of Infancy
and Childhood, 3rd Edition. Philadelphia, PA, W.B.
Saunders Company, 1987.
10. US Bureau of the Census: County and City Data
Book, 1967. US Government Printing Office, Washington,
DC, 1967.
11. US Bureau of the Census: County and City Data
Book, 1983. US Government Printing Office, Washington,
DC, 1983.
12. Wellington DG, Macdonald EJ, Wolf PF: Cancer
Mortality: Environmental and Ethnic Factors. New York,
NY, Academic Press, 1979, p. 228.
13. Segi M: Age-adjusted rates for cancer for selected
sites (A-classification) in 52 counties in 1973. Segi In-
stitute of Cancer Epidemiology. Nagoya, Japan, March,
1978.
14. US Bureau of the Census: County and City Data
Book, 1972. US Government Printing Office, Washington,
DC, 1972.
15. US Department of Health and Human Services:
Report of the Secretary’s Task Force on Black and Mi-
nority Health. Vol. 1. US Government Printing Office,
Washington, DC, 1985.
16. US Bureau of the Census: Statistical Abstract of the
United States 1988. 108th Ed. US Government Printing
Office, Washington, DC, 1987.
17. Mausner JS, Kramer S: Epidemiology — An In-
troductory Text. Philadelphia, PA, W.B. Saunders Com-
pany, 1965, pp. 72-76.
VOL. 87— NUMBER 9 SEPTEMBER 1990
711
The AM A
Hospital Medical Staff Section
Sixteenth Assembly Meeting
November 29 - December 3, 1990
The Peabody Orlando
Orlando, Florida
Highlights of the Interim Meeting will include:
• an educational program on Economic Credentialing;
• presentation by the AMA-HMSS Governing Council of reports on medical staff
issues including Health Care Cost, Waiver of Confidentiality Upon Application
for Reappointment and State Hospital Medical Staff Section (HMSS) Oversight
Peer Review Committee;
• recommendation of policy to the House of Delegates on Denial of Payment for
Pre-Existing Conditions, Third Party Payors and Patient Care Standards;
• AMA-HMSS Governing Council election for the position of Delegate.
For Information Contact:
Department of Hospital Medical Staff Services
American Medical Association
515 North State Street
Chicago, Illinois 60610
Phone (312) 464-4754 or 464-4761
NEW JERSEY MEDICINE
Intussusception in
Childhood
IRWIN H. KRASNA, MD
BONNA G. BENJAMIN, MD
JEFFREY L. ZITSMAN, MD
DAVID ROSENFELD, MD
We present our experiences with 41 consecutive cases of intussusception.
Most cases had a preliminary barium enema performed that successfully
reduced the intussusception in 12 cases. Twenty-nine patients were explored
surgically; bowel resection was carried out in 6 patients , and surgical reduc-
tion was carried out in 23 cases.
Intussusception in childhood is a well-known
entity to all pediatricians and pediatric sur-
geons. The typical idiopathic ileocolic in-
tussusception is characterized by a triad of colic,
abdominal mass, and currant jelly stools. The dis-
ease most frequently is seen in babies from two
months to two years of age, and the finding of a
“lead point” is rare in this age group (8 to 10 per-
cent). Ravitch popularized the use of hydrostatic
(barium enema) reduction at the Johns Hopkins
Hospital in 1939.1'7 It generally has been accepted as
the preferred method of reduction of intussuscep-
tion, with surgery being reserved for those children
Drs. Krasna, Benjamin, and Zitsman are affiliated with
the Division of Pediatric Surgery, and Dr. Rosenfeld is
affiliated with the Department of Radiology, UMDNJ-
Robert Wood Johnson Medical School. The manuscript
was submitted in March 1990 and accepted in May 1990.
Requests for reprints may be addressed to Dr. Krasna,
UMDNJ-Robert Wood Johnson Medical School, One
Robert Wood Johnson Place, CN-19, New Brunswick, NJ
08903.
where the barium enema fails to reduce the in-
tussusception completely.
We reviewed our experience at UMDNJ-Robert
Wood Johnson Medical School over a six-and-one-
half-year period. Fifty-six patients were referred to
the pediatric surgical service with a diagnosis of
intussusception; 41 patients had intussusception
confirmed and treated.
MATERIAL AND METHODS
We analyzed the records of all children referred
to the pediatric surgical service at UMDNJ-Robert
Wood Johnson Medical School, New Brunswick,
from June 1981 to February 1988, to rule out in-
tussusception. Patients were seen at Robert Wood
Johnson University Hospital or St. Peter’s Medical
Center. A total of 56 patients were referred, and
intussusception was confirmed in 41 patients. In all
patients, a flat (preliminary) film of the abdomen
was taken. If small bowel obstruction was present
on the flat plate, no attempt was made to reduce the
intussusception hydrostatically, but barium was
VOL. 87— NUMBER 9 SEPTEMBER 1990
715
56 Patients
Immediate OR (No BE) BE Flat film only
Figure 1 . Distribution of patients according to x-ray findings.
47 BE (6 to OR without BE)
No Intussusception Intussusception
Unable to reduce
by x-ray
Figure 2. Barium enema performed on 47 patients.
Intussusception
BE reduction
BE reduction
Surgical exploration
Following BE
Surgical exploration
Without BE
Reduction Resection
Reduction Resection
Figure 3. Patients with intussusception.
used only to confirm the location of the intussuscep-
tion— to plan the surgical incision.
If the preliminary x-ray was normal but in-
tussusception was suspected, the on-call radiologist
performed the barium enema following accepted
techniques. In some patients, a #24 or #30 French
Foley catheter was utilized and inflated with 15 to
30 cc of air. In other patients, the balloon was not
inflated, but the buttocks was taped; in some cases
A. Lead Point = 3
B. Perforation by BE = 1
C. Gangrenous Intussusception = 3
Lead Points
Ileal Duplication: 2
Meckel's Diverticulum: 1
Figure 4. Breakdown of the seven surgical
resections.
716
NEW JERSEY MEDICINE
Already reduced
Required resection
Surgical reduction
Figure 5. The breakdown for the 29 surgical procedures.
the buttocks was compressed manually. The barium
bag was elevated three feet above the tabletop prior
to the attempted hydrostatic reduction. Most of the
children were sedated and, unless there was free
reflux of barium into the small bowel, the child was
explored immediately after the enema.
If successful hydrostatic reduction was carried
out, the children were admitted to the hospital, kept
fasting, and given intravenous infusions until it was
obvious they did not re-intussuscept. In some cases,
crushed charcoal was placed in the stomach by
nasogastric tube, and when charcoal was present in
the stools, the children were fed. In other cases, the
children were fed when flatus was passed and the
abdomen was soft.
RESULTS
Distribution of patients according to x-ray find-
ings. As seen in Figure 1, of 56 patients referred with
a diagnosis of intussusception, 3 patients had flat
films, and on the basis of history and clinical evalu-
ations, were determined not to be suspicious for in-
tussusception and no barium enema was performed.
Six patients were taken to the operating room im-
mediately (without barium enema). Of these, 5 pa-
tients had an obvious intussusception with advanced
35
BE reduction Surgical reduction
Figure 6. The number of barium enemas showing
intussusception.
small bowel obstruction on x-ray, and no barium
enema was performed. One patient, who had a per-
foration of the cecum during the performance of the
barium enema at another hospital, was operated on
immediately, and had a bowel resection and an il-
eostomy performed. Forty-seven patients had
barium enemas after flat plates were taken.
Forty-seven patients had barium enemas per-
formed and intussusception demonstrated in 35 pa-
tients: 12 patients having a “normal” barium enema
(no intussusception) (Figure 2). In 12 of these 35
patients, complete reduction of the intussusception
was accomplished by barium enema and the pa-
tients were discharged without surgery and without
recurrence. In 23 patients, complete reduction of the
intussusception was not successful and the patients
were explored (Figure 3). In 2 of the 23 patients, the
intussusception was found to be completely reduced
at exploration (Figure 5).
Surgical reduction and surgical resection. Of 23
patients explored for failure of the barium enema to
reduce the intussusception, surgical reduction by
“milking” was accomplished in 19 patients, and in
4 patients a bowel resection (ileocolic) was carried
out. Similarly, of the 6 patients explored immedi-
ately, surgical reduction was accomplished in 4 pa-
tients, and a bowel resection was necessary in 2
patients (1 patient had a perforated cecum during
the performance of the barium enema) (Figure 4).
Of the 5 patients with advanced small bowel ob-
struction, only 1 patient required a bowel resection.
Of 29 surgical explorations, bowel resection was
necessary in 6 patients (21 percent) and surgical
reduction was carried out in 23 patients (79 percent)
(Figure 5).
Indication for surgical resection. One resection
was necessary because of perforation of the cecum
during the performance of a barium enema. After
successful surgical reduction, masses were noted in
two patients in the mesenteric surface of the ileum
and the cecum, ileal duplications acting as lead
points; ileocolic resections were carried out. In one
VOL. 87— NUMBER 9 SEPTEMBER 1990
717
29
Bloody stools Severe lethargy Cramps alone
73% Presented with bloody stools
Figure 7. The 29 surgical patients.
patient, an ileo-ileo-colic intussusception was pres-
ent and the lead point was an inverted Meckel’s
diverticulum. In view of the edema of the Meckel’s,
the abdomen was closed and three days later the
patient was re-explored and the diverticulum was
resected.
In three patients, an ileocolic resection was carried
out because a gangrenous, irreducible intussuscep-
tion was present. All surgical patients received anti-
biotics preoperatively and for five to seven days,
postoperatively. When no perforation was present, a
primary resection and anastamosis was carried out
on unprepared bowel, and no leakage or wound in-
fections occurred. Figure 5 outlines the surgical find-
ings in 29 surgical explorations.
Success rate of barium enema reduction. The
total number of successful barium enema reductions
was 12, or 34 percent of all the barium enemas show-
ing intussusception (Figure 6). If we include the 2
patients in whom the intussusception was found to
be reduced at exploration, the success rate of barium
enema reduction is 14 patients or 40 percent.
Presentation with bloody stools and other
methods of presentation. Twenty-seven of 41 pa-
tients presented with bloody stools (“currant jelly”),
an incidence of 65 percent. Of the 12 patients who
underwent successful barium enema reductions, 6
patients presented with bloody stools (50 percent).
The clinical features of 29 surgical patients are
shown in Figure 7. Seventy-three percent of those
patients requiring surgical exploration presented
with bloody stools, 13.5 percent presented only as
lethargy, and most of these patients had spinal taps
and were admitted with a diagnosis of meningitis or
sepsis, and 13.5 percent presented with colic alone.
Duration of symptoms. Accurate data on dura-
tion of symptoms were available on 26 surgical pa-
tients, and in 88 percent, symptoms were present
over 12 hours. Accurate data on the 12 hydrostatic
reductions were not available (Figure 8).
Time of year. Our data in Figure 9 did not demon-,
strate any increased incidence during any particular
season.
Barium enema of 12 patients without in-
tussusception. Twelve patients did not demonstrate
an intussusception on the barium enema, and their,
x-rays initially were reported as “normal.” On re-
view of their x-rays, although no intussusceptions
were found, the barium enemas were not without
pathology (Figure 10). In 6 patients, very significant
lymphoid polyposis of the colon or terminal ileum
were found (Figure 11). In 2 patients there was
significant “thumbprinting” (Figure 12) with edema
and spiculation of the mucosa consistent with Hen-
och-Schonlein purpura (HSP). In 2 patients, there
was severe spasm of the colon requiring intravenous
morphine sulfate to complete the barium enema
(one of these patients had both HSP with edema of
mucosa and severe spasm). In only 3 patients were
the enemas completely “normal.”
Total Surgical Explorations - 29 (26 Reported)
Under 12 hours = 3
12-24 hours = 1 1
24-48 hours = 6
Over 48 hours = 6
Figure 8. The duration of symptoms from the
study.
41 Cases
Fall = 9 (September, October, November)
Winter = 13 (December, January, February)
Spring = 8 (March, April, May)
Summer = 11 (June, July, August)
Figure 9. Time of the year for the study.
718
NEW JERSEY MEDICINE
Lymphoid Severe
polyposis spasm
Figure 10. The 12 patients with no intussusception.
HSP
and edema
of
mucosa
Negative
findings
DISCUSSION
Until Ravitch reintroduced hydrostatic reduction,
the time-honored treatment of intussusception was
surgical. In his classical textbook on pediatric sur-
gery, Gross opposed hydrostatic reduction because
of delay in operative intervention for those that are
irreducible; failure to reduce ileoileal intussuscep-
tions; and overlooking a lead point.8 Similarly, Potts
favored surgical treatment for the same reasons.9 At
the Johns Hopkins Hospital, hydrostatic pressure
has been the method of choice for the treatment of
intussusception since 1939, with excellent success to
1948. 1 Hirschsprung reported this technique in 1876,
and Hipsley, in Australia, reported 100 cases treated
by hydrostatic reduction, with a mortality of 5 per-
cent.10'12 The technique designed by Ravitch is
meticulous and demanding and uses a 45 cc Foley
bag fully inflated.2 Of 80 intussusceptions treated by
barium enema, 70 percent were reduced by barium
enema alone;1 Ravitch’s series probably has the best
success rate with hydrostatic pressure, and few re-
ports come close to his figures.4'7 If all centers fol-
lowed Ravitch’s recommendations meticulously, the
Figure 1 1 . Note the lymphoid polyposis of the
terminal ileum.
success rates probably would improve. Martin re-
ported a 55 percent success rate of barium enema
reduction.13 Coulter and Haller, when reviewing the
case material at Johns Hopkins Hospital in 1982,
had a 54 percent successful barium enema reduc-
tion.14 Our 34 percent success at barium enema does
not compare favorably with other series. A factor
may be the large number of different radiologists
performing the enemas. (In contrast to many
centers, our barium enemas were performed by on-
call radiologists — 20 radiologists, with different ex-
periences and training in pediatric radiology.)
Surgical exploration was carried out in cases
where the barium enema failed to reduce the in-
tussusception, and where the flat film showed me-
chanical small bowel obstruction. Barium enema re-
duction was not tried in the face of small bowel
obstruction because of a strong likelihood of an ileo-
ileal component, difficult to reduce by barium
enema, and the concern that small bowel obstruc-
tion may represent an ischemic intussusception.
However, a recent paper reported the safety and
success of barium enema reduction in spite of ap-
parent small bowel obstruction on the flat film.15
Figure 12. Note the thumbprinting and spiculation of
the mucosa in a case of Henoch-Schoenlein
purpura.
VOL. 87— NUMBER 9 SEPTEMBER 1990
719
Our patients had a high incidence of currant jelly
stools preceded by abdominal cramps (65 percent).
In many series, colic alone is the presenting symp-
tom, and if an intussusception is diagnosed before
bloody stools appear, the likelihood of successful
reduction by a barium enema is greater. In recent
years, lethargy has been reported as a presenting
symptom of intussusception.16 In rare cases, the
diagnosis of intussusception was made on the basis
of a quiet baby or lethargy alone. In most cases, the
appearance of bloody stools made the connection to
intussusception for the pediatrician. Perhaps, when
examining a baby for lethargy, a rectal should be
performed to look for currant jelly stools.
Twenty-three of 26 surgical cases had a history of
over 12 hours, and this may be responsible for the
failure of barium enema to reduce the intussuscep-
tion. One should suspect intussusception from
rhythmic colicky symptoms alone, even before
bloody stools are present. Barium enema in this
“early” group has a better chance of reducing the
intussusception.
There was no statistical difference in the season
of presentation. Ravitch found a peak in midsummer
and midwinter, and ascribed this to enteritis and
respiratory infections present in these periods.
Of the 12 barium enemas that were “normal,”
that is, they did not show an intussusception, nine
patients had pathology demonstrated on the barium
enema. Most commonly, significant lymphoid poly-
posis was seen either in the colon or in the terminal
ileum. Lymphoid polyposis is a self-limited con-
dition often seen in the terminal ileum and may be
the result of a viral illness or prior colostomy or
ileostomy, and is not a true polyp.17 It has been
reported as a lead point for intussusception.18'20
These six patients with lymphoid polyposis may
have had an intussusception, that reduced spon-
taneously, or a viral illness; either would explain the
crampy abdominal pain. Edema of the mucosa and
spiculation suggestive of HSP was seen in two cases,
and no surgery was indicated. In two cases, in-
testinal spasm of unknown origin was present in the
colon, requiring great effort to complete the barium
enema. Thus, these nine cases were not “normal”
but did not show an intussusception.
SUMMARY
Fifty-six children were referred by pediatricians to
a teaching hospital with three pediatric surgeons
over a six-and-one-half-year period. Forty-seven
children had barium enemas performed for diagnosis
and 35 children had intussusception demonstrated.
Barium enema reductions were carried out on 12
children (34 percent) and surgical explorations were
necessary in 29 children (66 percent). Six children
were operated upon immediately, without barium
enema. The low success rate of hydrostatic reduction
(34 percent) is in contrast to a success rate in the
literature of 55 to 70 percent. In addition, of the 12
patients who did not have an intussusception on
barium enema, 9 patients showed significant
pathology on the enema that probably accounted for
their complaints. ■
REFERENCES
1. Ravitch MM, McCune RM Jr: Reduction of in-
tussusception by hydrostatic pressure: An experimental
study. Bull Johns Hopkins Hosp 82:550, 1948.
2. Ravitch MM, McCune RM Jr: Reduction of in-
tussusception by barium enema: A clinical and ex-
perimental study. Ann Surg 128:904, 1948.
3. Ravitch MM, McCune RM Jr: Intussusception in
infants and children. J Pediatr 37:153, 1950.
4. Ravitch MM: Consideration of errors in the diagnosis
of intussusception. Am J Dis Child 84:17, 1952.
5. Ravitch MM: Intussusception in infancy and child-
hood; an analysis of 77 cases treated by barium enema.
N Engl J Med 259:1058, 1958.
6. Ravitch MM: Intussusception in Infants and Chil-
dren. Springfield, IL, Charles C. Thomas, 1959.
7. Ravitch MM: Pediatric Surgery. Chicago, IL, Year-
book Medical Publishers, 1962, pp. 751-765.
8. Gross RE: The Surgery of Infancy and Childhood.
Philadelphia, PA, W.B. Saunders Company, 1953, p. 228.
9. Potts WJ: The Surgeon and the Child. Philadelphia,
PA, W.B. Saunders Company, 1959, pp. 169-170.
10. Hirschsprung H: Tilfaelde of subakut tarmin-
vagination. Hospitalstid 3:321, 1876.
11. Hirschsprung H: 107 Falle von darminvagination
bei kinder, behandelt im konigin louisen kinderhospital in
Kopenhagen wahrend der jahre 1871-1904. Mitt Gremzgeb
Med Chir 14:555, 1905.
12. Hipsley PL: Intussusception and its treatment by
hydrostatic pressure: Based on an analysis of 100 con-
secutive cases so treated. MJ Australia 2:201, 1926.
13. Rosenkrantz JG, Cox JA, Silverman FN, Martin
LW: Intussusception in the 1970s: Indications for oper-
ation. J Pediatr Surg 12:367, 1977.
14. Coulter BB, Haller JA: Unpublished data, 1982.
15. Beasley SW, Campo JF: Radiological evidence of
bowel obstruction in intussusception. A contraindication
to attempted barium enema? Pediatr Surg 2:291, 1987.
16. Braun P, Germann I: Altered consciousness as a
precocious manifestation of intussusception in infants.
Nicod Z Kinderchir 33:307, 1981.
17. Leonidas JC, Krasna IH, Strauss L, et al.: Roentgen
appearance of the excluded color after colostomy for infan-
tile Hirschsprung’s disease. Am J Roentgenol, Radium
Therapy, Nuc Med 112:116, 1971.
18. Schenken JR, Kruger RL, Schultz L: Papillary
lymphoid hyperplasia of the terminal ileum: An unusual
cause of intussusception and gastrointestinal bleeding in
childhood. J Pediatr Surg 10:259, 1975.
19. Schifter P, Szakall SZ, Varbiro M, Pinter A: In-
testinal lymphoid hyperplasia causing pseudopolyposis.
Orv Hetil 121:2331, 1980.
20. Saito S, Tsuchida Y, Nishina T, et ah: Hyper-
trophic Peyer’s patch and infantile ileocecal intussuscep-
tion. Ann Pediatr Surg 1:7, 1984.
720
NEW JERSEY MEDICINE
Physicians’ Office
Laboratories
KATHLEEN L. VOLDISH, CLA (ASCP)
The number of physicians’ office laboratories (POLs) is increasing. Formal
technical education and certification for physician office laboratory personnel
assure more accurate results.
INSTRUMENT SELECTION
Question: With all the new instruments available
for physicians’ offices, how does a physician or his
staff know what instrument is right for the labora-
tory?
Answer: When evaluating instrumentation, two
aspects must be considered. Initially, the technical
feasibility must be considered. Economic feasibility,
however, also must be weighed carefully before a
new instrument is purchased.
Requests to consider a new procedure come from
many sources, including physicians, administrators,
sales representatives, or laboratory staff. From a
technical aspect, many questions must be ad-
dressed. For a specific test you should first consider
the time needed to perform the procedure. In other
words, will the results be available for diagnostic
value for the physician? Second, consider whether
the test requires special specimen collection or pa-
tient preparation. Mechanically, would the new
procedure need special space, complicated safety
Ms. Voldish is a registered technologist and laboratory
manager. Questions for this column can be addressed
to Ms. Voldish, 1150 Concord Drive, Haddonfield, NJ
08033.
features, alterations in plumbing, and/or additional
electrical outlets? Is your current laboratory struc-
ture capable of such modification? You also should
consider that after purchasing, will the required re-
agents be readily accessible and do they have special
storage requirements? From a technical aspect, how-
ever, just how valuable is the test for the laboratory’s
diagnostic requirements overall? For example, if you
are considering adding theophylline determinations
to your procedures, but the physician’s caseload for
asthmatics or related diseases is low, the technical
capability may be “overkill.” Each laboratory, of
course, is different.
Economic feasibility, in many cases, will override
technical aspects in management decisions. Most
suppliers can help get you started in evaluating the
instrument’s economic feasibility by performing a
cost analysis for your review. Many times, however,
this does not reveal parameters critical for your lab-
oratory environment. Because of the many economic
variables involved in matching a specific instrument
to a given laboratory, calculations based on your
workload should be done. Such variables to consider
are personnel (salaries and benefits), supplies,
equipment, space, service, and overhead. One way
that is useful is to determine the estimated number
VOL. 87— NUMBER 9 SEPTEMBER 1990
723
of tests to be performed on the instrument. Multiply
this number by the monthly consumable items (nee-
dles, drawing tubes, cuvettes, or pipettes) needed for
the test. Be sure to establish the monthly number
of quality control samples and calibrations required.
From this point, calculate the monthly reagent or kit
costs based on the volume of patients, quality con-
trol, and calibrations. Check the CAP workload
units per test and the hourly wages of the laboratory
personnel, and, with simple arithmetic, the esti-
mated direct monthly operation costs can be calcu-
lated. Although equipment costs can be allocated on
a five- to ten-year depreciation scale, do not forget
to add maintenance contract fees. The bottom line
is whether the laboratory’s workload merits the
economic capitalization and maintenance of a given
instrument, especially after allocation of overhead
expenses are assigned. These overhead expenses are
those that accrue in areas not directly identifiable
to a specific function and must be allocated on the
basis of either test volume or revenue. Some of these
expenses include building rent, operations, mainte-
nance, administration, bad debt, liability, and
education.
SAFETY TRAINING IN THE LABORATORY
Question: Our physician office laboratory has
been receiving safety data sheets from chemical
manufacturers when we place orders. In addition, I
have heard about OSHA requiring laboratories to do
special training. What is our responsibility as a
physician office laboratory (POL)?
Answer: As of August 1, 1988, all laboratories,
regardless of size, are required by the Occupational
Safety and Health Administration (OSHA) to have
a written Hazardous Communication Program in
place if hazardous chemicals are housed in the fa-
cility and handled by employees.
An inventory of all hazardous chemicals should
include the chemical’s name, location, quantity
stored per month, physical state (solid, liquid, or
gas), the chemical’s hazard classification, the manu-
facturer’s name and address, and any pertinent ad-
ditional information.
Once the inventory is complete, a letter to each
manufacturer of every potentially hazardous
chemical in the laboratory should be sent to obtain
a Materials Safety Data Sheet (MSDS). The orig-
inal MSDS must be retained in the laboratory along
with the inventory list; both should be updated an-
nually.
The next step is to plan a Hazard Communication
Standard (HCS) educational program and retain a
written copy of the program in the workplace. Train-
ing can be done on each specific chemical, e.g.
picric acid, or categories of hazards, e.g. solvents.
The law specifically requires each program to in-
clude behavioral objectives covering the following
items: location of hazardous chemicals in the work-
place; location of the HCS written program,
chemical inventory, and MSDS; environmental
monitoring, if appropriate; physical and health haz-
ards of the chemicals in the workplace; employee
protection measures including work practices,
emergency procedures, and protective equipment;
and program details including the laboratory system
and MSDS as well as how to use these systems.
Ah employees are to be trained within 30 days of
employment and always before being assigned to
work with a hazardous chemical. When a new haz-
ard is introduced into the workplace, additional
training should be conducted by the employee’s im-
mediate supervisor. The HCS program must be a
regular, continuing effort with review sessions held
annually. Documentation of the training must be in
written records permanently retained by the POL.
Each POL employee should have a full under-
standing of the MSDS forms. The ingredient section
of the MSDS lists the ingredients of the chemical
and sets forth the permissible eight-hour occupa-
tional exposure — the threshold limit value. The
physical data section explains the physical and
chemical characteristics including boiling point,
specific gravity, solubility, appearance, and odor.
The fire and explosive hazard data section identifies
any special precautions that should be taken during
fire fighting. The health-hazard data section
provides information about tolerable exposure
levels, carcinogenicity, how the chemical enters the
human system, and first-aid procedures. In ad-
dition, each employee should receive a list that
identifies which chemicals affect specific organs,
along with signs and symptoms of poisoning.4
The MSDS form also provides reactivity data
(how and under what conditions chemicals react),
environmental protection procedures (handling
methods, what to do if spills occur, and how to
dispose of products), and other precautions (eye,
skin, and respiratory protection, special ventilation,
and how to handle contaminated equipment).5
Even if employees handle only sealed containers,
as in the receiving area, possible leakage and break-
age present serious risks. These employees who are
exposed to hazardous chemicals need to be informed
of proper protection and emergency procedures and
should be included in the hazard communication
program.
OSHA has started inspecting laboratories to see
that personnel have received formal education and
training about hazardous chemicals. Careful com-
pliance with the Hazard Communication Standard
will ensure OSHA approval and safe laboratory
practice. ■
724
NEW JERSEY MEDICINE
Focal Candida
Hepatitis
in a Patient with Richter’s Syndrome
J.G. BARONE, MD
C.A. ABOUCHEDID, MD
R.L. MOSER, MD
This may be the first case of Richter’s syndrome (Hodgkin’s lymphoma or
histiocytic lymphoma occurring with chronic lymphocytic leukemia) com-
plicated by focal Candida hepatitis.
Reticulum cell sarcoma occurring in a patient
with chronic lymphocytic leukemia (CLL)
first was reported by Richter in 1928. 2 Since
that time, Hodgkin’s lymphoma also has been ob-
served in patients with CLL.3 The term Richter’s
syndrome (RS) has been applied to both associa-
tions. We present a case of RS complicated by focal
Candida hepatitis. We discuss the problems as-
sociated with the diagnosis and treatment of focal
Candida hepatitis in a patient with RS and we re-
view the literature.
CASE REPORT
A 52-year-old female had a ten-year history of
asymptomatic stage 0 CLL (Table 1). One month
before admission, she developed enlarged cervical
lymph nodes and was treated with the alkylating
agent chlorambucil (Leukeran®) for suspected pro-
gression to stage I CLL. Adenopathy decreased with
treatment, but the patient required admission to St.
Francis Medical Center, Trenton, because of pro-
From St. Francis Medical Center, Trenton, where Dr.
Barone is a resident in surgery, Dr. Abouchedid is an
attending surgeon, and Dr. Moser is director of
pathology. This paper was submitted in September 1989
and accepted in May 1990. Requests for reprints may be
addressed to Dr. Joseph Barone, 464 Northam Drive,
North Brunswick, NJ 08902.
gressive weakness, weight loss, and new onset of
right upper quadrant abdominal pain. Physical
examination revealed massive ascites and hepa-
tomegaly. Serum bilirubin was 148 ;umol/L (normal
range: 2-18 /umol/L), alkaline phosphatase was 786
nfL (normal range: 30-115 /u/L) , lactate de-
hydrogenase was 2,284 yu/L (normal range: 100-225
/u/L), and aspartate aminotransferase was 225 n/L
(normal range: 7-40 nfL). Hepatitis B surface anti-
body and antigen were negative. Ultrasound of the
biliary system was normal. Abdominal com-
puterized tomography (CT) showed multiple space-
occupying hepatic defects (Figure 1).
Thin-needle aspiration liver biopsy was done
under CT control. Aspirated material contained a
diffuse mixed small and large cell type malignant
lymphoma (Table 2). One day after the biopsy, our
patient developed symptoms of an acute abdomen
and was taken as an emergency to the operating
room. At laparotomy, surgeons found a diffuse ma-
lignant gastric lymphoma, mixed small and large
cell type. There were two areas of gastric perforation
caused by extensive lymphomatous involvement
with necrosis. Two perigastric lymph nodes were in-
volved by CLL alone. A partial gastrectomy was
performed. The liver was enlarged but was without
discrete nodules. Wedge biopsy of the liver demon-
strated necrosis and the same malignant lymphoma.
In addition, invasive pseudohyphae of Candida
VOL. 87— NUMBER 9 SEPTEMBER 1990
727
Figure 1. Computed tomography scan demonstrating multiple
space-occupying hepatic lesions. Differentiation between
lymphomatous and fungal involvement is not possible.
# 1*
■ftft
*
* 4 * w
V *
Figure 2. Wedge liver biopsy demonstrating necrosis and both
budding yeast and invasive pseudohyphae of Candida (periodic
acid-Schiff stain, 480x).
albicans were seen penetrating the liver biopsy
specimen (Figure 2).
Intraoperative peritoneal cultures grew Candida
albicans. Multiple blood, urine, sputum, and central
venous catheter tip cultures and stains were negative
Table 1. RAI clinical staging for CLL.*
Stage 0: Lymphocytosis alone.
Stage I: Enlarged nodes.
Stage II: Splenomegaly, hepatomegaly, or both.
Stage III: Anemia (HgB less than 11 g/dL).
Stage IV: Thrombocytopenia (platelets less than
100,000).
*Rai KR, Sawitsky A, Cronkite EP: Clinical staging of chronic
lymphocytic leukemia. Blood 46:219, 1975.
Table 2. International working formulation.*
Low-Grade Lymphoma
Small lymphocytic cell
Follicular, mixed cleaved cell
Follicular, mixed small cleaved and large cell
Intermediate Grade Lymphoma
Follicular, large cell
Diffuse, small cleaved cell
Diffuse, mixed small cleaved cell
Diffuse, large cell
High-Grade Lymphoma
Large-cell immunoblastic
Lymphoblastic cell
Small noncleaved cell
‘Non-Hodgkin’s lymphoma pathological class project. NCI-
sponsored study of classification of non-Hodgkin's lymphoma:
Survey and description of a working formulation for clinical
usage. Cancer 49:2112, 1982.
for fungus. Amphotericin B was started on the first
postoperative day; however, the patient died ten
days after surgery from multisystem organ failure.
DISCUSSION
RS is a rare event occurring in less than 10 percent
of patients with CLL.1 There is no definitive con-
clusion regarding the histological characterization of
the malignancies in RS. Immunological studies of
tumor cells have shown some reticulum cell
sarcomas and Hodgkin’s lymphomas associated with
RS originate from lymphoid B-cells.1 Therefore, it
has been suggested that histiocytic lymphomas in
RS represent a B-monoclonal immunoblastic
lymphoma that arise from the initial B-cell
neoplasm.3 Immunochemistry techniques using
monoclonal and polyclonal antibodies identified
both B-lymphocytic and monocytic-histiocytic cell
lines of differentiation.5 Leukemic transformation of
a multipotential stem cell could explain the simul-
taneous occurrence of two distinct cell populations;
however, morphological and immunological evi-
dence indicates the possibility of developing two in-
dependent malignancies is unusual.6,7 It is possible
that chemotherapy for the initial leukemia could
promote the development of a second malignancy,
but this is unlikely considering the usually short
time from administration of chemotherapy to emer-
gence of the second malignancy.5
The clinician should suspect RS if a patient with
CLL develops systemic symptoms such as weight
loss and weakness associated with local or diffuse
lymph node enlargement unresponsive to standard
treatment protocols for CLL (chlorambucil and
radiotherapy). Diagnosis of RS most often is estab-
lished by lymph node biopsy that demonstrates the
development of a malignant lymphoma in a patient
728
NEW JERSEY MEDICINE
who previously had CLL. Lymph nodes may contain
both leukemic and lymphoma cells that may rep-
resent an early stage of RS.1 2 3 4 5 6 This may explain why
our patient's cervical nodes decreased in size after
chlorambucil treatment. It is possible that the
alkylator effectively treated the leukemic portion of
the node thus decreasing the node mass. It is likely,
however, that the lymphoma was not affected.
The prognosis for patients with RS is poor. The
results of chemotherapeutic regimens incorporating
cyclophosphamide, Adriamycin™, Vincristine®, and
prednisone have been disappointing.3,5 Remission
has been reported, but median survival time is about
four months.4,5 Multisystem organ failure caused by
dissemination of the lymphoma is the usual cause
of death.
Patients with RS and other critical illnesses are
at risk for developing fungal infection.8,9 Potential
risk factors that contribute to fungemia in these
patients include malignancy, the use of chemo-
therapy, corticosteroids, and broad-spectrum anti-
biotics.8,9 By altering the normal flora of the
gastrointestinal tract, overgrowth of fungus can
occur and cause gastric mucosal injury and permit
translocation of the fungus into the bloodstream.10
Reports of focal Candida infection in the liver with
negative systemic cultures suggest that the portal
vein is the initial passageway for Candida from the
gastrointestinal tract to the blood.11,12 In our case,
focal liver candidiasis and negative systemic cul-
tures for fungus support this mechanism of infection.
Clinically, focal Candida hepatitis presents with
fever, right upper quadrant abdominal pain, and
elevated liver enzymes.11,12 The most consistent
biochemical abnormality is an extreme elevation of
the alkaline phosphatase level.9 All systemic fungal
cultures are negative. The CT scan helps to establish
the diagnosis; however, in patients with RS, CT
differentiation between lymphomatous and fungal
hepatic involvement is not possible. Also, per-
cutaneous liver biopsy can be misleading due to
sampling error. In our patient, a liver biopsy done
at the time of laparotomy was the only diagnostic
test sensitive enough to establish the diagnosis.
Patients with focal Candida hepatitis require
prompt treatment with intravenous amphotericin B
since the liver may act as a filter, delaying systemic
fungal infection.9 This function of the liver may
provide the clinician with a window of time to treat
the hepatic infection before systemic infection oc-
curs.7 Even with early treatment, the prognosis is
poor: 34 percent mortality.3 Liposomal-encapsulated
amphotericin B enhances drug actions and may be
an effective and less toxic alternative treatment.13,14
CONCLUSION
The development of fever, right upper quadrant
abdominal pain, elevated liver enzymes, and CT
scan showing evidence of focal hepatic degeneration
in immunocompromised patients should raise the
suspicion of Candida hepatitis. Open liver biopsy
may be necessary to establish the diagnosis. Strong
consideration should be given to empiric amphoter-
icin B therapy while awaiting culture and biopsy
results to prevent potential fungal dissemination.8
Editor’s note. It will be interesting to find out
whether the newly released fluonazole will do a bet-
ter job than amphotericin B. ■
REFERENCES
1. Aisenberg AL, Long JC: Lymphocyte surface charac-
teristics in malignant lymphoma. Am J Med 58:300-306,
1975.
2. Richter MN: Generalized reticular cell sarcoma of
lymph nodes associated with lymphocytic leukemia. Am
J Pathol 4:285-299, 1928.
3. Trump DL, Mann RB, Phelps R, et al.: Richter’s
syndrome: Diffuse histiocytic lymphoma in patients with
chronic lymphocytic leukemia. A report of five cases and
review of the literature. Am J Med. 68:539-548, 1980.
4. Harousseau JL, Flandrin G, Tricot G, et ah: Malig-
nant lymphoma supervening in chronic lymphocytic
leukemia and related disorders. Cancer 48:1302-1308,
1981.
5. Neame PB, Soamboonsrup P, Browman G, et ah:
Simultaneous or sequential expression of lymphoid and
myeloid phenotypes in acute leukemia. Blood 65:142-148,
1985.
6. Perentesis J, Ramsey NKC, Brunning R: Bipheno-
typic leukemia: Immunological and morphological
evidence for a common lymphoid-myeloid progenitor in
humans. J Pediatr 102:63, 1983.
7. Hershfeld MS, Kurtzberg J, Harden E, et ah: Con-
version of stem cell leukemia from a T-lymphoid to a
myeloid phenotype reduced by the adenosine deaminase
inhibitor 2’ deoxycoformycin. Proc Natl Acad Sci 81:253,
1984.
8. Alden SM, Frank E, Flancbaum L: Abdominal can-
didiasis in surgical patients. Am Surg 55:45-49, 1989.
9. Haron E, Fled R, Tuffnel P, et ah: Hepatic can-
didiasis: An increasing problem in immunocompromised
patients. Am J Med 83:17-26, 1987.
10. Solomkin JS, Flohr AB, Quie PG, Simmons RL:
The role of Candida in intraperitoneal infections. Surgery
88:524-530, 1980.
11. Maksymiuk AW, Thongprasert S, Hopfer R, et ah:
Systemic candidiasis in cancer patients. Am J Med
77:20-27, 1984.
12. Lewis JH, Patel HR, Zimmerman HJ: The spec-
trum of hepatic candidiasis. Hepatology 2:479-487, 1982.
13. Bartley DL, Huges WT, Parvey LS, et ah: Com-
puted tomography of hepatic and splenic abcesses in
leukemic children. Pediatr Infect Dis 1:317-321, 1982.
14. Lopez-Berestein G, Hopfer RL, Mills K, et ah:
Liposomal amphotericin B is toxic to fungal cells but not
to mammalian cells. Biochem Biophys Acta 770:230-234,
1984.
VOL. 87— NUMBER 9 SEPTEMBER 1990
729
Because safety
cannot be taken for grantee
in H ^-antagonist therapy
Minimal potential for
drug interactions
Unlike cimetidine and ranitidine.1
Axid does not inhibit the cytochrome
P-450 metabolizing enzyme system.2
Swift and effective
H2-antagonist therapy
■ Most patients experience
pain relief with the first dose3
■ Heals duodenal ulcer
rapidly and effectively4 5
■ Dosage for adults with active
duodenal ulcer is 300 mg once nightly
(150 mg b.i.d. is also available)
References
1 . USP 0/ Update. September/ October 1988, p 120
2 Br J CUn Pharmacol 1985:20:710-713.
3. Data on file. Lilly Research Laboratories.
4. Scand J Gastroenterol 1987:22fsuppt 136) 61-70.
5 Am J Gastroenterol 1989:84:769-774.
AXID"
nizatidine capsules
Brief Summary. Consult the package literature tor complete
information.
Indications and Usage: t . Active duodenal ulcer -tor up to eight weeks
of treatment Most patients heal within four weeks.
2. Maintenance therapy- tor healed duodenal ulcer patients at a
reduced dosage ot 150 mg h.s. The consequences ot therapy with Axid
tor longer than one year are not known.
Contraindication: Known hypersensitivity to the drug. Use with caution
in patients with hypersensitivity to other Hrreceptor antagonists.
Precautions: General- 1. Symptomatic response to nizatidine therapy
does not preclude the presence ot gastric malignancy.
2. Dosage should be reduced in patients with moderate to severe
renal insufficiency.
3. In patients with normal renal function and uncomplicated hepatic
dystunction, the disposition of nizatidine is similar to that in normal
subjects.
Laboratory Tes/s-False-positive tests tor urobilinogen with Multistix*
may occur during therapy.
Drug Interactions -No interactions have been observed with theophyl-
line. chlordiazepoxide, lorazepam, lidocaine, phenytoin. and warfarin. Axid
does not inhibit the cytochrome P-450 enzyme system; therefore, drug
interactions mediated by inhibition ot hepatic metabolism are not expected
to occur. In patients given very high doses (3,900 mg) ot aspirin daily,
increased serum salicylate levels were seen when nizatidine, 150 mg
b i d., was administered concurrently.
Carcinogenesis , Mutagenesis, Impairment ot Fertility- A two-year oral
carcinogenicity study in rats with doses as high as 500 mg/kg/day
(about 80 times the recommended daily therapeutic dose) showed no
evidence ot a carcinogenic effect. There was a dose-related increase in
the density ot enterochromatfin-like (ECL) cells in the gastric oxyntic
mucosa. In a two-year study in mice, there was no evidence ot a
carcinogenic effect in male mice, although hyperplastic nodules ot the
liver were increased in the high-dose males as compared with placebo.
Female mice given the high dose ot Axid (2,000 mg/kg/day, about 330
times the human dose) showed marginally statistically signiticant
increases in hepatic carcinoma and hepatic nodular hyperplasia with no
numerical increase seen in any ot the other dose groups. The rate ot
hepatic carcinoma in the high-dose animals was within the historical
control limits seen for the strain ot mice used. The female mice were
given a dose larger than the maximum tolerated dose, as indicated
by excessive (30%) weight decrement as compared with concurrent
controls and evidence ot mild liver injury (transaminase elevations). The
occurrence ot a marginal linding at high dose only in animals given
Axid* (nizatidine, Lilly)
an excessive and somewhat hepatotoxic dose, with no evidence ot a
carcinogenic effect in rats, male mice, and female mice (given up to
360 mg/kg/day, about 60 times the human dose), and a negative
mutagenicity battery are not considered evidence ot a carcinogenic
potential tor Axid.
Axid was not mutagenic in a battery of tests performed to evaluate its
potential genetic toxicity, including bacterial mutation tests, unscheduled
DNA synthesis, sister chromatid exchange, mouse lymphoma assay,
chromosome aberration tests, and a micronucleus test
In a two-generation, perinatal and postnatal fertility study in rats, doses
ot nizatidine up to 650 mg/kg/day produced no adverse effects on the
reproductive performance ot parental animals or their progeny.
Pregnancy -Teratogenic Ettects-Pregnancy Category C— Oral repro-
duction studies in rats at doses up to 300 times the human dose and in
Dutch Belted rabbits at doses up to 55 times the human dose revealed
no evidence ot impaired fertility or teratogenic effect; but, at a dose
equivalent to 300 times the human dose, treated rabbits had abortions,
decreased number ot live tetuses, and depressed tetal weights. On intra-
venous administration to pregnant New Zealand White rabbits, nizatidine
at 20 mg/kg produced cardiac enlargement coarctation of the aortic
arch, and cutaneous edema in one fetus, and at 50 mg/kg, it produced
ventricular anomaly, distended abdomen, spina bifida, hydrocephaly,
and enlarged heart in one fetus. There are, however, no adequate and
well-controlled studies in pregnant women, it is also not known whether
nizatidine can cause fetal harm when administered to a pregnant woman
or can affect reproduction capacity. Nizatidine should be used during
pregnancy only if the potential benefit justities the potential risk to
the fetus.
Nursing Mothers- Studies in lactating women have shown that
0.1% ot an oral dose is secreted in human milk in proportion to plasma
concentrations. Because of growth depression in pups reared by treated
lactaiing rats, a decision should be made whether to discontinue nursing
or the drug, taking into account the importance of the drug to the mother.
Pediatric L/se-Satety and effectiveness in children have not been
established.
Use in Elderly Pat/enfs-Healing rates in elderly patients were similar
to those in younger age groups as were the rates ot adverse events and
laboratory test abnormalities. Age alone may not be an important factor
in the disposition ot nizatidine. Elderly patients may have reduced
renal (unction.
Adverse Reactions: Clinical trials of varying durations included almost
5,000 patients. Among the more common adverse events in domestic
placebo-controlled trials ot over 1,900 nizatidine patients and over 1,300
on placebo, sweating (1% vs 0.2%), urticaria (0.5% vs <0.01%), and
somnolence (2.4% vs 1.3%) were signiticantly more common with
nizatidine. It was not possible to determine whether a variety ot less
common events was due to the drug.
Axid* (nizatidine, Lilly)
Hepafe-Hepatocellular injury (elevated liver enzyme tests or alkaline
phosphatase) possibly or probably related to nizatidine occurred in some
patients. In some cases, there was marked elevation ( >500 IU/L) in SG0T
or SGPT and, in a single instance, SGFT was >2,000 IU/L The incidence
ot elevated liver enzymes overall and elevations of up to three times
the upper limit of normal, however, did not significantly differ from that
in placebo patients. Hepatitis and jaundice have been reported. All
abnormalities were reversible after discontinuation ot Axid.
Cardiovascular- In clinical pharmacology studies, short episodes
ot asymptomatic ventricular tachycardia occurred in two individuals
administered Axid and in three untreated subjects.
CA/S-Rare cases ot reversible mental contusion have been reported.
Endocnne-C\mica\ pharmacology studies and controlled clinical trials
showed no evidence ot antiandrogenic activity due to nizatidine.
Impotence and decreased libido were reported with equal frequency by
patients on nizatidine and those on placebo. Gynecomastia has been
reported rarely.
Hematologic- Fatal thrombocytopenia was reported in a patient
treated with nizatidine and another H2-receptor antagonisL This patient
had previously experienced thrombocytopenia while taking other drugs.
Rare cases ot thrombocytopenic purpura have been reported.
Integumental -Sweating and urticaria were reported signiticantly
more frequently in nizatidine- than in placebo-treated patients Rash and
exfoliative dermatitis were also reported.
Hypersensitivity -As with other Hrreceptor antagonists, tare cases ot
anaphylaxis following nizatidine administration have been reported.
Because cross-sensitivity among this class has been observed, Hweceptor
antagonists should not be administered to those with a history of hyper-
sensitivity to these agents Rare episodes of hypersensitivity reactions
(eg. bronchospasm, laryngeal edema, rash, and eosinophilia) have been
reported.
Other- Hyperuricemia unassociated with gout or nephrolithiasis was
reported. Eosinophilia, fever, and nausea related to nizatidine have been
reported.
Overdosage: Overdoses of Axid have been reported rarely. It overdosage
occurs, activated charcoal, emesis, or lavage should be considered along
with clinical monitoring and supportive therapy. Renal dialysis for tour
to six hours increased plasma clearance by approximately 84%.
PV 2098 AMP [091289]
Additional information available to the profession on request
Eli Lilly and Company
Indianapolis, Indiana
46285
N2-2924-B-049310 ©1990, EU LILLY AND COMPANY
Axid* (nizatidine. Lilly)
730
NEW JERSEY MEDICINE
CASE REPORT
Familial Polyposis Coli
& Gardner’s Syndrome
W. MARK NANNERY, MD
JOSEPH G. BARONE, MD
CLAUDE ABOUCHEDID, MD
Familial polyposis coli and Gardner’s syndrome are genetically inherited
defects causing multiple adenomatous polyps of the colon with a propensity
for malignant degeneration. To emphasize that neoplasm of the ampulla of
Vater is the most frequently reported extracolonic gastrointestinal neoplasm,
we present a case report and a review of the literature.
Familial polyposis coli (FPC) was first de-
scribed in 1859 as a condition associated
with multiple adenomatous polyps present
throughout the large intestine. The polyps may
number from a few hundred to thousands lining the
colon. The disease is transmitted as an autosomal
dominant genetic defect, occurring in approximately
1 in 8,300 live births.1
Gardner and Richards first described the triad of
Drs. Nannery and Barone are residents in surgery and
Dr. Abouchedid is an attending in general surgery, St.
Francis Medical Center, Trenton. This paper was sub-
mitted in April 1990 and accepted in May 1990. Requests
for reprints may be addressed to Dr. Nannery, St. Francis
Medical Center, 601 Hamilton Avenue, Trenton, NJ
08629.
colonic polyposis, benign osteomas of the skull and
mandible, and soft tissue tumors such as epidermoid
cysts in 1953. After the investigation of seven family
members, the triad now known as Gardner’s syn-
drome (GS), like FPC, appeared to be inherited as
an autosomal dominant genetic defect.2 Other ab-
normalities such as dental anomalies and desmoid
tumors have been reported and now are accepted as
additional manifestations of GS.
More recently, it has been recognized that most
patients with FPC or GS will manifest an even wider
spectrum of extracolonic gastrointestinal tract (GIT)
involvement. The distinction between FPC and GS
has been subject to debate: it has been suggested
that they represent the same single gene mutation
with variable penetrance or expression, accounting
VOL. 87— NUMBER 9 SEPTEMBER 1990
731
CASE REPORT
for the differences between the two entities, and
possibly for the wide spectrum of extracolonic GIT
manifestations seen in both.3
Regardless of the variety of their manifestations,
it is clinically important to recognize FPC or GS
because of the greater than 95 percent incidence of
carcinoma of the colon in untreated individuals. In
untreated patients, the average age for appearance
of adenomas is 24.5 years, and the average age for
the diagnosis of colon cancer is 39.2 years.4
Figure 1. ERCP showing obstruction of the distal common bile
duct.
Figure 2. Histologic specimen of periampullary region. Normal
common bile duct is to the left. To the right, is invasion of the
distal duct by a well-differentiated periampullary carcinoma.
For many years, it was accepted that adenomas
in FPC or GS were limited to the colon and that total
colectomy was curative. However, recent recognition
of benign and malignant neoplasms of the upper GIT
has created the need for a more extensive workup
of newly diagnosed FPC or GS patients and a closer
followup throughout their lives. Colectomy now is
considered the initial step in the long-term manage-
ment of these patients.
Recognized extracolonic GIT manifestations have
included neoplasms of the stomach, duodenum, am-
pulla of Vater, pancreaticobiliary tree, and small
intestine; periampullary location most frequently is
encountered.
CASE REPORT
The patient is a 49-year-old male belonging to a
pedigree with known GS. At 26 years of age, he was
found to have multiple colonic polyps as well as
benign osteomas of the skull. In 1970, a total colec-
tomy and proctectomy was performed at 32 years of
age, with evidence of invasive carcinoma in one of
the polyps.
The patient was readmitted in November 1987
with partial intestinal obstruction secondary to il-
eostomy stenosis, weight loss of eight pounds over
two months, and a history of persistent itching of a
few weeks’ duration that prompted specific biliary
tree studies.
Admission laboratory studies included white
blood cell count of 9.4 x 103 cells/ml3; hemoglobin of
15.6 g/dL; and hematocrit of 46.2 percent. Abnormal
values included amylase of 285 U/L, and alkaline
phosphatase of 785 U/L. All other laboratory values
were within normal limits. Ultrasound and com-
puted tomography (CT) scan of the gallbladder,
liver, and pancreas were normal. Endoscopic retro-
grade cholangiopancreatography (ERCP) with
biopsy was performed revealing an obstructing
tubulovillous adenoma with atypia involving the
ampulla of Vater (Figure 1).
Three weeks later, a Whipple procedure (pan-
creaticoduodenectomy) was performed as definitive
treatment for a large periampullary carcinoma. His-
tological examination revealed a primary, well-dif-
ferentiated papillary adenocarcinoma arising in a
mixed tubulovillous adenoma involving the am-
pullary region with invasion of the distal common
bile duct (Figure 2). All lymph nodes were negative
for carcinoma. The postoperative course was slow
but uneventful. When last seen in May 1989, the
patient presented no evidence of recurrence and had
normal bilirubin and liver enzyme values.
DISCUSSION
Abdominal colectomy with ileoproctostomy had
been the accepted initial treatment for FPC or GS
732
NEW JERSEY MEDICINE
CASE REPORT
since the report of McKenney in 1939.1 2 3 4 5 However, a
long-term study by Moertel found that cancer of the
rectal stump developed in 59 percent of patients
followed for 23 years after surgery.6 The median in-
terval from ileoproctostomy to cancer is 14 years.7
This study prompted reconsideration of surgical
treatment with total proctocolectomy and either a
standard or a continent ileostomy as an accepted
alternative. More recently, in an effort to maintain
acceptable anal sphincter control and continence,
ileoanal endorectal pull-through procedures were de-
veloped with maintenance of nervous innervation to
the rectal musculature and genitalia.
At the time of diagnosis of FPC or GS, upper GIT
endoscopy, and duodenoscopy should be performed.
After colectomy, periodic endoscopic examination of
the upper and lower GIT should be considered in all
patients at an interval of every one to three years.
Early detection and coagulation or excision of poten-
tially premalignant lesions may prevent malignant
transformation, thereby improving the prognosis of
these patients.
Neoplasms at the ampulla of Vater are the most
frequently reported extracolonic GIT pathology,
originally estimated as occurring in 2 to 15 percent
of patients.8 However, in a series of 17 patients with
GS, Shemesh discovered adenomas at one or more
sites in the upper GIT in all patients, most frequent-
ly at the ampulla of Vater (64.7 percent of patients).9
Adenomas also were seen in the duodenum (47 per-
cent), stomach (29.4 percent), and small intestine
(23.57 percent).
Similar prospective studies from Japan on 24 FPC
patients also revealed a high incidence (50 percent)
of periampullary adenomas, and a total upper GIT
incidence of 70 percent.10
It is probable that extracolonic GIT neoplasms
increase in size and number during life, and most
patients may be expected to develop them during
followup. Adenomas of the ampulla of Vater show
a greater tendency for dysplasia than those of the
stomach or small bowel, resulting in a more frequent
occurrence of malignancy at that site.
The mean time for development of periampullary
carcinoma has been estimated at 15.7 years after the
diagnosis of FPC or GS; the average age of patients
when this diagnosis is made is 48 years.11
During endoscopic followup, a high prevalence of
small tubular adenomas is expected. Biopsy speci-
mens of all polyps at the ampulla should be ob-
tained. Villous adenomas and larger tubular
adenomas should be removed because of their malig-
nant potential. Endoscopic polypectomy may be
considered if the polyp is pedunculated, separate
from the ampulla, and safely and adequately resec-
table. Large villous polyps and symptomatic, large
tubular adenomas require open surgical excision.
Preoperative ERCP is helpful in determining the
extent of ductal involvement, but caution must be
exercised in interpretation of the results of en-
doscopic biopsy, as it is not always possible to obtain
representative specimens. Whipple’s procedure
should be considered if invasive carcinoma is evident
or strongly suspected.
SUMMARY
FPC and GS are genetic disorders treated initially
by total colectomy. As more has been learned about
these entities, it has become apparent that lifetime
followup of affected patients now is necessary.
The wide spectrum of extracolonic GIT mani-
festation has made periodic endoscopy necessary fol-
lowing total colectomy. Early detection and coagula-
tion or excision of potentially premalignant
neoplasms may prevent malignant degeneration and
improve the long-term survival of these patients.
This case presentation and review stress the im-
portance of periodic specific examination of the am-
pulla of Vater, and the application of appropriate
ablative therapy. ■
REFERENCES
1. Sleisenger MH, Fordtran JS: Gastrointestinal Dis-
eases; Pathophysiology, Diagnosis, and Management. 2nd
Edition. Philadelphia, PA, W.B. Saunders Co., 1978.
2. Shemesh E, Bat L: A prospective evaluation of the
upper gastrointestinal tract and periampullary region in
patients with Gardner’s syndrome. Am J Gastroent
80:825, 1985.
3. Ewald R: Gardner’s syndrome with adenoma of the
common bile duct. Acta Chir Scand Suppl 520:63, 1984.
4. Bussey HJ: Familial Polyposis Coli. Baltimore, MD,
Johns Hopkins University Press, 1975.
5. McKenney DC: Multiple polyposis; congenital, here-
dofamilial malignant. Am J Surg 46:204, 1939.
6. Moertel C, Hill J, Adson M: Surgical management
of multiple polyposis. Arch Surg 100:521, 1970.
7. Watne A, Carrier J, et al.: The occurrence of
carcinoma of the rectum following ileoproctostomy for
familial polyposis. Ann Surg 83:550, 1977.
8. Pauli RM, Pauli ME, Hull JG: Gardner’s syndrome
and periampullary malignancy. Am J Med Gent 6:205,
1980.
9. Shemesh E, Pines A, Bat L: Spectrum of extracolonic
gastrointestinal tract involvement in Gardner’s syndrome.
Isr J Med Sci 21:973, 1985.
10. Sugihara K, Muto T, Kamiya J, et al.: Gardner’s
syndrome associated with periampullary carcinoma,
duodenal and gastric adenomatosis. Dis Colon Rectum
25:766, 1982.
11. Berk T, Friedman L, Goldstein S, et al.: Relapsing
acute pancreatitis as the presenting manifestation of an
ampullary neoplasm in a patient with familial polyposis
coli. Am J Gastroent 80:627, 1985.
VOL. 87— NUMBER 9 SEPTEMBER 1990
733
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734
NEW JERSEY MEDICINE
■ TRUSTEES’ MINUTES*
A regular meeting of the Board
of Trustees was held on July 15,
1990, at the executive offices in
Lawrenceville. Detailed minutes
are on file with the secretary of
your county society. A summary of
significant actions follows:
President’s Report . . .
(1) PRO versus MSNJ . . .
Noted that MSNJ prevailed in this
litigation; physicians may be rep-
resented by an attorney if cited by
PRO on a quality issue.
(2) MIIENJ President . . . Heard
that Mr. Daniel Goldberg will as-
sume the position of president of
the Medical Inter-Insurance Ex-
change of New Jersey.
(3) National Practitioner Data
Bank . . . Noted that the Data
Bank will be operational in the fall
with files on all adverse records of
insurance carriers, licensing
boards, and medical societies.
(4) Appointment of AMA Del-
egate . . . Unanimously approved
the appointment of Dr. Harry M.
Carnes as AMA delegate and Dr.
Douglas M. Costabile as AMA
alternate delegate. Also, approved
the following:
That the Board not endorse candidates
for AMA elective offices (excluding
candidates for the AMA Hospital
Medical Staff Section Governing
Council) during the next 12-month
period.
(5) AMA Outreach Program . . .
Announced new member recruit-
ment reached an all-time high.
(6) Meeting with HCFA and
Pennsylvania Blue Shield . . .
Noted that all resolutions from the
1990 House of Delegates must be
executed.
Executive Director Report . . .
(1) MSNJ Paid Membership , . .
Noted that membership as of June
30, 1990, totalled 9,395 with 7,149
regular dues-paying members; a
complete report on all membership
categories will be available on a
regular basis for those interested.
(2) MSNJ Financial Statements
. . . Reviewed and approved the
financial statements for the period
ending April 30, 1990.
(3) Litigation . . . Reviewed the
following items: no-fault: filed suit
concerning the $100 license
assessment issue and a ban on bal-
ance billing; malpractice sur-
charge: will be tried in the ap-
pellate division in September;
physical therapy regulations: de-
cision was reversed, upholding the
physical therapy regulations; office
of the ombudsman: legal firm of
Kern, Augustine, Conroy & Isele
will proceed with legal action
against regulations; medical waste
registration/refunds: processed re-
imbursements for responding
physicians and other 40 percent
need to respond to the DEP mail-
ing; physician assistants: legal
arguments will be presented by
Judge Herbert J. Stern; and op-
tometric drug bill: not sufficient
support in the Democratic Caucus
to bring the bill to a vote.
(4) MSNJ Annual Meeting . . .
Agreed to be prepared to rec-
ommend an alternative site for the
1991 meeting if MSNJ does not
succeed in reaching mutually
agreeable terms with the Taj
Mahal Casino Resort.
Specialty Reports . . . Received
informational reports from
UMDNJ, the Academy of Medi-
cine of New Jersey, and the New
Jersey Hospital Association.
Committee on Environmental
Health . . . Approved the follow-
ing recommendation:
That the Board of Trustees advise
DEP that the Society urges adoption
of the following: That a more com-
prehensive waste program be for-
mulated, including a reduction of ma-
terials through composting and other
forms of segregation and recycling;
that the necessity of recycling be re-
duced by lowering the amounts of
available packaging and other dis-
posable materials by regulations and/
or incentives; that the use of compost-
ing be maximized to reduce the volume
of material that must be otherwise dis-
posed of.
Letters were sent to the DEP com-
missioner stating MSNJ believes
in a waste management program
emphasizing reduction of ma-
terials, recycling, and composting,
and offering assistance with con-
cerns about the disposal of low-
level radioactive waste materials.
AMA Annual Meeting . . . Noted
the following from Dr. Karl T.
Franzoni’s report: Dr. Palma For-
mica’s election to a three-year
term on the AMA Board of
Trustees, Dr. Robert J. Weier-
man’s election to a two-year term
as secretary of the AMA-HMSS
governing Council, and Dr. James
S. Todd’s selection as AMA ex-
ecutive vice-president; a report on
the status of Health Access Ameri-
ca; status of New Jersey resolu-
tions including: adoption of a
substitute resolution on Medicare
billing requirement incorporating
New Jersey’s resolution; interim
meeting location would remain in
VOL. 87— NUMBER 9 SEPTEMBER 1990
735
Chicago with the possibility of
another type of AMA meeting in
Washington, DC; resolution re-
questing Congress to require Part
B carriers to provide guidelines in
understandable language that
clearly identify noncovered ser-
vices and medically unnecessary
services and asking Congress to es-
tablish an appeals process for
physicians and patients to be in-
itiated in a timely fashion before a
determiniation that a service is
noncovered or medically unneces-
sary were placed on the consent
calendar and adopted; reaffirmed
AMA policy concerning gender ex-
ploitation in the workplace; the
first portion of Resolution #15 (tax
deductions for uncompensated
care) was refered to the AMA del-
egation and noted that AMA pol-
icy does not support a special in-
come tax deduction for providing
medical care to the indigent; and
referred the resolution concerning
national health insurance to the
AMA delegation for report back to
the Board; and the AMA Board re-
iterated its opposition to socialized
or national health care in response
to MSNJ’s Resolution #16 (no to
national health insurance).
MIIENJ Legislative Committee
Report . . . Received a report from
Robert A. Mauerer, DO, dealing
with two actions: the first directed
the legislative committee proceed
with its plan for passage of struc-
tured verdict legislation during the
current session of the Legislature;
and directed the Committee to
proceed with its plan to achieve
modification of court rules in the
areas of prejudgment interest, ar-
bitration, and bifurcation of these
issues.
New Business . . . Noted the fol-
lowing items: Dr. Frank J. Malta
will investigate the delay in issuing
CDS renewal certificates; vote of
support for DO representation for
SBME; and authorization for
president to appoint four MSNJ
members to serve on the newly
created Medicare Physicians Ad-
visory Council. □
HHMSNJ AUXILIARY M
Addressing the needs of juve-
niles and seniors has been the focus
of recent health projects in Passaic
and Gloucester counties. MSNJA
applauds both auxiliaries for rec-
ognizing a community problem
and successfully developing a pro-
gram to solve it.
In Paterson, Passaic County, 20
percent of the children belong to
single-parent families and many
others have two working parents. A
large number of elementary school
children care for themselves after
school and older children frequent-
ly are given responsibility for their
younger brothers and sisters — all
too often with tragic results. Area
medical centers routinely treat
young children injured in the
absence of parents. Nationwide,
close to three million children
under the age of five require medi-
cal care due to accidents in the
home. Such statistics prompted
the Passaic County Medical So-
ciety Auxiliary and the Northern
New Jersey Health Planning
Council to devise and cosponsor a
babysitting training program to
educate low-income children be-
tween the ages of 9 and 13 to be
good emergency mother substi-
tutes for their younger siblings.
The aim of the program was to
protect the safety of young chil-
dren six months old to eight years
old by teaching their babysitters
the latest medical information on
safe child care — how to prevent in-
juries and what to do in the event
of an emergency.
The joint efforts of the Auxiliary
and the Council resulted in a four-
part program held on Monday
afternoons in April at the Paterson
Public Library. In attendance were
35 students from Paterson Schools
6 and 21. The sessions dealt with
common sense in caring for chil-
dren. Volunteers — a physician,
nurses, teachers, a Consumer
Products Safety Commission rep-
resentative, an American Red
Cross worker, and auxiliary mem-
bers— taught the children basic
child care information; the stages
of child development; safe games
and toys for toddlers; first aid and
choking rescue techniques; fire
prevention; promotion of language
and early learning; and specific
practical advice on the prevention I
of accidents. Encouraged by the re-
sults of the Paterson project, the
organizers are hoping to expand
the program to other cities.
Targeting the elderly popu-
lation, the Gloucester County
Medical Society Auxiliary de-
veloped a two-part geriatric health
project — “Staying Active After
Sixty” and “Adopt-A-Nursing
Home.” The goal of “Staying Ac-
tive After Sixty” was to challenge
our attitudes toward aging by of-
fering senior citizen groups and
nursing homes an excellent in-
spirational film that emphasizes it
ARE YOU MOVING?
Name
Old Address
City State Zip
New Address
City State Zip
736
NEW JERSEY MEDICINE
is never too late to improve fitness
through good nutrition, exercise,
and the reduction of stress. To ac-
company the film, the Auxiliary’s
health education committee de-
vised two separate discussion
guides — one designed for groups of
older persons, and one for their
caretakers. In addition, pretests
and post-tests are available to de-
termine if and how attitudes have
changed after viewing the film. Be-
cause this is not a time-limited
project, groups in the community
will be able to utilize and benefit
from the program for years to
come. The second project involves
“adopting” the Shady Lane Nurs-
ing Home in Clarksboro. The Aux-
iliary has made an ongoing com-
mitment to provide artwork and
wall decorations, to brighten the
milieu in this county facility. Sev-
eral times a year, they also will
donate fresh-cut flowers that resi-
dents can arrange and use in ac-
tivity projects. Finally, the Aux-
iliary hopes to procure a fine quali-
ty piano so that various entertain-
ment groups can make special ap-
pearances at the home. □ Marion
H. Geib
■HAMNJ REPORT***
The Academy of Medicine’s An-
nual Awards Dinner, held on May
30, 1990, at the Chanticler in Short
Hills, was a success. Approximate-
ly 350 guests attended to honor our
award recipients and to help in-
stall our officers for the 1990-1991
year. Our Edward J. Ill Award re-
cipient, Dr. Leighton Cluff, and
our Citizen’s Award designee,
Arline Schwartzman, both were
eloquent in their responses. A
special touch to the evening was
the invocation delivered by the
Reverend Claudia Kalis, Dr.
Cluff s daughter.
The location for our 1991 event
again will be the Chanticler and
the date will be May 29, 1991. The
Awards Committee, under the
chairmanship of immediate past-
president, Dr. Frederick Cohen, is
soliciting nominations for 1991.
The deadline for receiving nomi-
nations is September 17, 1990.
New AMNJ officers for
1990-1991 elected at the Awards
Dinner were President, Stanley S.
Bresticker, MD; President-Elect,
Gerald Shapiro, MD; First Vice-
President, George J. Hill, MD;
Second Vice-President, John L.
Krause, MD; Secretary, Palma
Formica, MD; and Treasurer, Alan
Herschman, MD.
The Academy’s staff actively is
preparing the Annual Calendar for
1990-1991. The Calendar will in-
clude many items of interest in-
cluding CME activities for the up-
coming academic year, a list of
available roving symposia topics,
an application to participate in our
Speaker’s Bureau, and a list of af-
filiated specialty societies and
their presidents.
On Saturday, October 20, 1990,
the Academy of Medicine will
sponsor a major symposium on
magnetic resonance imaging at the
Hyatt Regency Hotel in New
Brunswick. The Radiological So-
ciety of New Jersey will cosponsor
this event and Dr. Michael Kessler
is the program chairman. Among
the guest presenters will be Dr.
Robert Grossman from the Hospi-
tal of the University of Penn-
sylvania who will discuss MRI of
the brain and Dr. Jeffrey Weinreb
of the New York University Medi-
cal Center who will discuss MRI of
the abdomen and pelvis. Locally,
Dr. Reuben Mezrich, director of
MRI at the Robert Wood Johnson
University Hospital will discuss
the latest applications of MRI.
The Academy will continue our
special series on socioeconomic,
political, and ethical issues. The
series, formally known as the
“First Wednesday” series, will be
entering its eighth year. On Tues-
day, September 25, 1990, an eve-
ning program on living wills will be
held in cosponsorship with the
Bergen County Medical Society
and the Citizen’s Committee on
Biomedical Ethics. Panelists will
include Senator Gabe Ambrosio
and Dr. Michael Nevins. On
Wednesday, November 7, 1990,
New Jersey State Department of
Health Commissioner Dr. Frances
Dunston will address a luncheon
meeting at our headquarters in
Lawrenceville. Dr. Dunston will
discuss issues that are impacting
on the health department. □
Stanley Bresticker, MD, President
H PLACEMENT FILE Wffi
The following physicians have
written to the executive offices of
MSNJ seeking information on pos-
sible opportunities for practice in
New Jersey. The information has
been supplied by the physicians. If
you are interested in any further
information concerning these phy-
sicians, we suggest you make in-
quiries directly to them.
INTERNAL MEDICINE
Anan Adnan Faidi, MD, 30 Charles St.
W, Apt. 1717, Toronto, Ontario, IM4Y
1R5 Canada. Jordan 1983. Board certi-
fied. Also, board eligible (ENDO-
CRIN). Group. Available.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner-
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital-based. Available.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Wood-
side Ave., Trenton, NJ 08618. Rutgers
1980. Board certified. Part time or full
time. Available.
SURGERY
Donna Vecchione, MD, 27700 Bishop
Park Dr., 4025, Willoughby Hills, OH
44092. SUNY-Stony Brook 1985.
Board eligible. Partnership, solo,
multispecialty group. Available.
UROLOGY
Ronald G. Frank, MD, 380 Rector PL,
Apt. 11J, New York, NY 10280. New
York Medical 1985. Group or partner-
ship. Available July 1991.
737
VOL. 87— NUMBER 9 SEPTEMBER 1990
Physicians
Are OftenThe First
To Know.
As a physician, you often encounter emotional illnesses or
alcohol and drug dependence problems in your patients.
The most difficult question then is where to refer patients for
the best treatment. The answer for many has been Carrier Founda-
tion, a private, non-profit hospital serving adolescents and adults on
both an inpatient and outpatient basis.
Among the best known specialized hospitals of its kind in the
region, Carrier treats substance dependence, eating disorders such as
anorexia nervosa and bulimia, phobias and obsessive-compulsive dis-
orders, mood disorders including depression and other psychiatric
illnesses.
Carrier’s treatment programs meet the highest standards of
psychiatric care — standards that have been identified with Carrier
Foundation for 80 years. A unified treatment approach brings
together the skills of psychiatrists, psychologists, nurses, certified
alcoholism counselors (CAC), clinical social workers and allied
clinical therapists.
Carrier Foundation, in Belle Mead, New Jersey, is centrally
located for an easy drive from almost anywhere in the State as well as
eastern Pennsylvania. Most major forms of insurance are honored.
The Public Relations Department is happy to give patients and/or
their families tours of the facilities when arranged by appointment. If
you would like to have more information about Carrier, please call
1-800-223-0207, outside New Jersey, 201-874-4000.
Carrier Foundation. We’re putting lives back together.
Carrier Foundation
Belle Mead, New Jersey 08502
NEW JERSEY MEDICINE
— —
CONTINUING EDUCATION
ALLERGY
October
19 General Allergy
1-2 P.M. — North Princeton
Developmental Center, Princeton
(AMNJ)
25- In Vitro Allergy Seminar
28 Myrtle Beach, Martinique
(Holy Name Hospital)
ANESTHESIOLOGY
November
20 Meeting
6-9 P.M. — Ramada Inn, Clark
(New Jersey State Society
of Anesthesiologists)
CARDIOLOGY
October
10 Early Intervention in Cardiac
Problems
12:30-5 P.M. — Bristol-Myers-
Squibb Corp., Lawrenceville
(Mercer Medical Center
and AMNJ)
23 Sudden Cardiac Death
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
27- Cardiac Surgery: 1991
28 8 A.M. -5 P.M. — Bally’s Park Place
Hotel & Casino, Atlantic City
( Cooper Hospital/University
Medical Center)
November
20 Current Strategy in the
Management of Arrhythmias
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
DERMATOLOGY
October
9 Dermatology Meeting
7-9 P.M. — Schering Corporation,
Kennilworth
(Dermatological Society of
New Jersey)
10 Common Tumors of the Skin
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
17 Advances in Dermatologic
Therapies
9 A.M. -5 P.M. — UMDNJ-Robert
Wood Johnson Medical School,
Piscataway
(UMDNJ)
November
13 Dermatology Meeting
7-9 P.M. — Schering Corporation,
Kennilworth
(Dermatological Society of
New Jersey)
INFECTIOUS DISEASE
October
I AIDS Training and Resource
Program for Hospital Health
Educators
11:30 A.M. -1 P.M. — University
Hospital, Newark
(AMNJ)
4 Counseling and Testing for HIV
Infection
11:45 A.M.-l P.M. —John F.
Kennedv Medical Center, Edison
(AMNJ and NJDOH)
10 Identification and Management
of HIV Infection
9:30-10:30 A.M. — Bergen Pines
County Hospital, Paramus
(AMNJ and NJDOH)
10 Infectious Disease Conference
8 A.M. -5 P.M. — Somerset Medical
Center, Somerville
(Somerset Medical Center)
I I Circle of Support: Caring for
Children and Families with HIV
8 A.M. -4 P.M. — Tropworld,
Atlantic City
(AMNJ)
1 1 Identification and Management
of HIV Infection
11 A.M. -12 Noon— Hunterdon
Developmental Center, Clinton
(AMNJ and NJDOH)
1 1 Clinical Management of HIV
Infection
11:45 A.M.-l P.M.— John F.
Kennedy Medical Center, Edison
(AMNJ and NJDOH)
17 Diagnosis and Treatment of
AIDS
8- 9 A.M. — Barnert Hospital,
Paterson
(AMNJ and NJDOH)
17 Clinical Management of HIV
Infection
9- 10 A.M. — Raritan Valley
Community College,
North Branch
(AMNJ and NJDOH)
November
6 Diagnosis and Treatment of
AIDS
8-9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ and NJDOH)
8 Issues and Perspectives:
Neuropsychiatric and
Psychosocial Aspects of AIDS
8:30 A.M. -3:15 P.M. —Clarion
Hotel, Edison
(UMDNJ)
12 Identification and Management
of HIV Infection
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
MEDICINE
October
1 8th Annual Corneal Transplant
15 9 A.M. -3:30 P.M. —UMDNJ,
29 Newark
(UMDNJ)
2 Grand Rounds
9 8:30-10 A.M. — Elizabeth General
16 Medical Center, Elizabeth
23 (Elizabeth General
30 Medical Center)
3 Aminoglycosides
9-10 A.M. — Warren Hospital,
Phillipsburg
(AMNJ)
3 Prevention of Lower Extremity
Amputations
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
3 Diagnosis and Treatment of
Neuroleptic Malignant
VOL. 87— NUMBER 9 SEPTEMBER 1990
739
TOWARD
2000 VI
SYMPOSIUM
October
12th
and 13th.
The sixth annual
Toward 2000
Symposium is an
opportunity to
assess progress
toward the goal of
reducing cancer mortality in the United
States. The symposium will be held at Fox
Chase Cancer Center on October 12th and
13th. National experts will conduct seminars,
workshops and informal dinner discussions
focusing on common
solid malignancies
including lung, colon,
and breast. Faculty
will also discuss
advances in
autologous bone marrow transplantation and
the role of immunotherapy.
For more information and hotel
accommodations, please contact Kathy Smith
or Louise Blasick at (215) 728-2715.
As an organization accredited by the Accreditation Council for Continuing Medical
Education, Temple University School of Medicine certifies that this program meets the criteria
for 12 credit hours of Category I, provided it is completed as designed.
With support from Bristol-Myers Oncology Division.
FOX CHASE
CANCER CENTER
DISCOVERY & HOPE.
7701 Burholme Avenue, Philadelphia, PA 19111
740
NEW JERSEY MEDICINE
3
3
4
9
9
9
9
23
10
11
11
11
13
13
13-
14
Syndrome
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
Biomedical Ethics
9 A.M.-l P.M. — New Jersey
Medical School, Newark
(UMDNJ)
Management of Elevated
Cholesterol in the Elderly
1:30-2:30 P.M.— HIP/RCHP,
New Brunswick
(RCHP and AMNJ)
Biological Origins of Alcoholism
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
How To Mend a Broken Heart
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
Cosmetics: Choosing, Using,
and Reactions to Them
7- 9 P.M. — Schering Corporation,
Kenilworth
(Dermatological Society of
New Jersey)
Prevention of Lower Extremity
Amputations
8- 9 A.M. — Barnert Hospital,
Paterson
(AMNJ)
Topics in Public Health
12:15-1:30 P.M. — John Fitch
Plaza, Trenton
(AMNJ and NJDOH)
Lupus
9 A.M. -4:30 P.M. — Hoffmann-
LaRoche, Nutley
(Lupus Foundation)
Cocaine Addiction
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
Severe Limb-Threatening
Ischemia
12 Noon-1 P.M. — Community
Medical Center, Toms River
(Community Medical Center)
Diabetic Nephropathy
1:30-2:30 P.M. — Vineland
Developmental Center, Vineland
(AMNJ)
Late Effects of Polio
8 A.M. -3:30 P.M. — Somerset
Marriott Hotel, Somerville
(Raritan Valley Post Polio
Support Group)
Cooper Medical Alumni
Association
1-7 P.M. — Hyatt, Cherry Hill
( Cooper Hospital/University
Medical Center) 29
Masoidectomy
7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
Rheumatology
1-4 P.M. — Great Gorge Resort,
Vernon Valley
(UMDNJ)
Meeting
6:30 P.M. — The Manor,
West Orange
(Neurological Association of New
Jersey /Neurology Section, AMNJ)
Citrate and Nephrolithiasis
Overlook Hospital, Summit
(Nephrology Society of
New Jersey)
Bone Marrow Transplant
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
Chronic Pain Management and
Issues Related to Iatrogenic
Addiction
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
Prevention of Lower Extremity
Amputations
1-2 P.M. — V.A. Medical Center,
Lyons
(AMNJ)
Diagnosis and Treatment of
Nicotine Addiction
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
Clinical Advances in MRI
and CT
9 A.M. -5 P.M. — Sheraton at
Woodbridge Place, Iselin
(UMDNJ)
New Practice Program
8 A.M. -3:30 P.M. —Medical
Society of New Jersey,
Lawrenceville
(MIIENJ)
MRI Seminar
8 A.M. -5 P.M. — Hyatt Regency,
New Brunswick
(Radiology Society of New Jersey)
Sexuality Today
8:30 A.M. -4:30 P.M. — Holiday Inn,
Somerset
(UMDNJ)
Meeting
6:30-9:30 P.M. — The Manor,
West Orange
(Head and Neck Oncology
Society/ AMNJ)
Newer Antibiotics
12 Noon-1 P.M. — Mercer Medical
Center, Trenton
(Mercer Medical Center and
AMNJ)
Sports Medicine
5:30-8 P.M. — Robert Wood
Johnson Medical Center,
New Brunswick
(UMDNJ)
30 Management of Type II
Diabetes
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
31 Fall Refresher
8-4:30 P.M. — Sheraton at
Woodbridge Place, Iselin
(New Jersey Academy of Family
Physicians)
November
1- Sinus Endoscopy
2 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
3 Obesity Update
8 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
4 Advances in Colony-
Stimulating Factors
9 A.M.-l P.M. — Ramada
Renaissance, East Brunswick
(UMDNJ)
6 Grand Rounds
13 8:30-10 A.M. — Elizabeth General
20 Medical Center, Elizabeth
27 (Elizabeth General
Medical Center)
7 Emergency Medical Care
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
7 Newer Concepts in Asthma
Management
1:30-2:30 P.M.— HIP/RCHP,
New Brunswick
(RCHP and AMNJ)
8 Annual Meeting
8 A.M. -4 P.M. — Hyatt Regency,
New Brunswick
(NJ Society of Critical Care
Medicine)
8 Diabetic Nephropathy
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ)
11 Diabetic Nephropathy
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
12 Hyperalimentation
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ)
12 Renal and Pancreatic
Transplantation Update
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
13 Management Symposium
7-9 P.M. — Schering Corporation,
13-
14
15
16
16
17
17
18
20
20
20
25-
27
25
26
/OL. 87— NUMBER 9 SEPTEMBER 1990
741
prnf? Hahnemann Department of Medicine
University GRAND ROUNDS
SEPTEMBER, 1990
September 5, 1990
CORONARY HEART DISEASE AND HOW
TO PREVENT IT
William Roberts, MD
Chief, Pathology Branch, NHLBI, NIH
Clinical Professor of Medicine (Cardiology),
and Pathology
Georgetown University, Washington, DC
September 12, 1990
DIAGNOSIS OF HIV INFECTION
Charles J. Schleupner, MD
Associate Professor of Medicine
University of Virginia School of Medicine
Chief, Infectious Diseases Section
VA Medical Center, Salem, VA
September 19, 1990
METABOLIC, NEUROLOGIC AND
HEMATOLOGIC MANIFESTATIONS OF
SPHINGOLIPIDOSIS
A. Charles Winkelman, MD
Professor of Clinical Neurology
Director, Neuro-Ophthalmology
Hahnemann University
S. Benham Kahn, MD
Professor and Vice Chairman
Neoplastic Diseases
Hahnemann University
David A. Wenger, PhD
Professor of Medicine, Biochemistry and
Molecular Biology
Jefferson Medical College
Philadelphia, PA
September 26, 1990
CRITICAL CARE MEDICINE: ALVEOLAR
EDEMA AND TISSUE OXYGEN TRANSPORT
Michael A. Mathay, MD
Associate Professor of Medicine and
Anesthesia, Director, MICU, UCSF
San Francisco, CA
David R. Dantzker, MD
Professor and Director
Pulmonary and Critical Care Medicine
University of Texas Medical School
Houston, TX
OCTOBER, 1990
October 3, 1990
PITUITARY ADENOMAS: DIAGNOSIS AND
TREATMENT
WEDNESDAYS
8:30 a. m. -9:30 a.m.
September-December, 1990
Peter Snyder, MD
Associate Professor of Medicine
Division of Endocrinology
University of Pennsylvania School of
Medicine
Philadelphia, PA
October 10, 1990
CHANGING PATTERNS OF AIDS AND THE
LUNGS
Philip C. Hopewell, MD
Professor of Medicine
University of California, SF
Chief, Chest Service, San Francisco
General
Hospital, CA
October 17, 1990
DIVISION OF CARDIOLOGY CLINICAL
RESEARCH: CARDIAC IMAGING
Eric L. Michelson, MD
Professor of Medicine
Director, Division of Cardiology
Hahnemann University
October 24, 1990
CARDIAC REMODELING: CLINICAL
IMPLICATES AND THERAPEUTIC
OPTIONS
Gervasio A. Lamas, MD
Assistant Professor of Medicine
Harvard Medical School, Boston, MA
October 31, 1990
DIABETIC NEPHROPATHY
Eli A. Friedman, MD
Professor of Medicine
Chief, Division of Renal Disease
SUNY Health Science at Brooklyn, NY
NOVEMBER, 1990
November 7, 1990
STEROID ABUSE IN THE ATHLETE
Robert Cantu, MD
Chairman of Surgery
Director, Services of Sports
Medicine
Emerson Hospital, Concord, MA
Consultant, Sports Medicine
Committee
USA American Boxing Federation
November 14, 1990
CONTROVERSIES IN NON-CARDIAC CHEST
PAIN (Gastro-Esophageal Reflux, Achalasia)
Sidney Cohen, MD
Professor and Chairman of Medicine
Temple University School of Medicine
Philadelphia, PA
November 21, 1990
DIVISION OF PULMONARY MEDICINE AND
CRITICAL CARE
Edward Schulman, MD
Associate Professor of Medicine
Director, Division of Pulmonary and Critical
Care Medicine
Hahnemann Universtiy
November 28, 1990
MEDICAL MANAGEMENT OF DEPRESSION
AND ANXIETY
Gary Tollefson, MD, PhD
Associate Professor of Psychiatry
University of Minnesota, MN
Jonathan O. Cole, MD
Chief, Psychopharmacology Program
McLean Hospital, Belmont, MA
DECEMBER, 1990
December 5, 1990
PTCA VS BYPASS GRAFT SURGERY FOR
CORONARY ARTERY DISEASE
William S. Frankl, MD
Vischer Professor of Medicine and
Chairman,
Department of Medicine
Director, Likoff Cardiovascular Institute
Hahnemann University
December 12, 1990
ABNORMALITIES OF THROMBOSIS AND
THROMBOEMBOLISM
Daniel Deykin, MD
Chief of Medicine, Director, Health Services
Research and Development
Boston VA Medical Center, MA
December 19, 1990
AGING OF THE SKIN
Richard L. Speilvogel, MD
Professor of Medicine and Dermatology
Director, Division of Dermatology
Hahnemann University
WEDNESDAY MEDICAL SEMINAR SERIES
8:30 a.m. -3:30 p.m.
September 26, 1990
CRITICAL CARE
October 10, 1990
AIDS TREATMENT
November 7, 1990
MEDICINE IN ATHLETICS
November 28, 1990
MEDICAL MANAGEMENT OF
DEPRESSION AND ANXIETY
December 12, 1990
ABNORMALITIES OF THROMBOSIS
AND THROMBOEMBOLISM
Seminar Directors:
William S. Frankl, MD
Professor of Medicine
and Chairman
Department of Medicine
Allan B. Schwartz, MD
Professor of Medicine
Director, Continuing
Medical Education for the
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd FI. New College Bldg.
Hahnemann University
15th Street Entrance
15th & Vine Streets
Philadelphia, PA
Hahnemann University designates this continuing medical education activity
for 1 hour-for-hour credit in Category I of the Physician's Recognition Award
of the American Medical Association.
For Information, call the Office of Continuing Education at (215) 448-8263
> i
742
NEW JERSEY MEDICINE
Kenilworth
(Dermatological Society of
New Jersey)
14 Coding Workshop
9 A.M. -3 P.M. — MSNJ
Headquarters, Lawrenceville
(Urology Society of New Jersey)
14 Fall Refresher Course
8 A.M. -4 P.M. — Sheraton Hotel,
Woodbridge
(NJ Academy of Family
Physicians)
14 Cocaine Express
9:15 A. M. -4:30 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
14 Proper Use of Endoscopy
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
14 Diabetic Nephropathy
1:30-2:30 P.M. — Roosevelt
Hospital, Metuchen
(AMNJ)
15 Partial Hospitalization and Its
Psychotherapeutic Role
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
15- Third Conference on
17 Radioimmunodetection and
Radioimmunotherapy of Cancer
All day — Princeton University,
Princeton
( Center for Molecular Medicine
and Immunology)
17 The Breast
8 A.M. -2 P.M. — Sheraton Poste
Inn, Cherry Hill
( Cooper Hospital/University
Medical Center)
17 Office Computer Seminar
8 A.M. -4 P.M. — Hyatt Regency
Hotel, New Brunswick
(MSNJ and AMNJ)
17 Slide Seminar: Bone Marrow
and Spleen
9 A.M.-l P.M. — Robert Wood
Johnson Medical School,
New Brunswick
(NJ Society of Pathologists)
20 Chronic Epstein-Barr Virus
8- 9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
21 Diabetic Nephropathy
9- 10 A.M. — Warren Hospital,
Phillipsburg
26 Sports Medicine
5:30-8 P.M. — Robert Wood
Johnson Medical School,
New Brunswick
(UMDNJ)
27 Parkinson Disease
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
28 Clinical Update in Pulmonary
Medicine
8 A.M. -5:20 P.M. — Deborah Heart
and Lung Center, Browns Mills
(Deborah Heart and Lung Center)
28 New Practice Program
8 A.M. -3:30 P.M.— MSNJ
Headquarters, Lawrenceville
(MIIENJ)
29- Hypnosis in Couples and Family
30 Therapy
8:30-4:30 P.M.— UMDNJ
(UMDNJ)
30 Sickle Cell Disease
12 Noon-1 P.M. — Mercer Medical
Center, Trenton
(Mercer Medical Center)
OBSTETRICS/GYNECOLOGY
October
2 Diabetes in Pregnancy
8-10 A.M. — Barnert Hospital,
Paterson
(AMNJ)
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address.
City
. State .
Zip.
New Address.
City
. State.
Zip.
Two Special Issues Available
The History of , Disease
Women Physicians ^ew £reey
in New Jersey in "ew dersey
Send $6.50 for each issue:
NEW JERSEY MEDICINE
Medical Society of New Jersey
Two Princess Road
Lawrenceville, NJ 08648
VOL. 87— NUMBER 9 SEPTEMBER 1990
743
f
PHILADELPHIA HEART INSTITUTE
of Presbyterian Medical Center
I Cardiology
Update **
designed for the physician and provides an intensive
survey of the current status of clinical cardiology . . .
Wednesday, October 3, 1990 3:00-5:00 PM
The Electrocardiogram
Moderator: Ami Iskandrian, M.D.
3:00-3:20
Interesting and important
electrocardiographic findings
Leonard N. Horowitz, M.D.
3:20-3:40
The benefits and limitations of
exercise electrocardiography
Norman Feinsmith, M.D.
3:40-4:00
Slides of ECGs (unknowns) will be
presented and discussed.
4:00-5:00
Case Presentations
Panel Discussion
David L. Scher, M.D.
Robert I. Katz, M.D.
Terry Langer, M.D.
Steven f. Nierenberg, M.D.
f. David Ogilby, M.D.
Gary f. Vigilante, M.D.
■ Case Presentations and Panel Discussions
■ CME Credits*
■ No Registration Fee
■ Call for Reservation 662-8627
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
‘The Philadelphia Heart Institute at Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
Presbyterian Medical Center designates this continued medical education activity for 2 credit hours in Category I of
the Physicians’ Recognition Award of the American Medical Association and the Pennsylvania Medical Society
Membership requirement. Nine sessions, 18 credits.
Ml — j
744 NEW JERSEY MEDICINE
ll I TT— T— ^1^—1
16 Diabetes in Pregnancy
8-9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
18 Neonatal Problems
7:30-8:30 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
19 Maternal Transport
8 A.M. -1:30 P.M. — The Mansion,
Main Street, Voorhees
( Cooper Hospital/University
Medical Center)
20 Hypertensive Disease in
Pregnancy
9 A.M. -4:30 P.M. — Saddle Brook
Marriott, Saddle Brook
(Seton Hall University Graduate
School of Medical Education)
November
2 Semi-Annual Meeting
8 A.M. -5 P.M. — Sheraton
Meadowlands Hotel, Secaucus
(NJ Obstetrical and
Gynecological Society)
4- Fifth Annual Issues and
7 Controversies in Ob/Gyn
7 A.M.-l P.M. — Contemporary
Hotel, Walt Disney World,
Lake Buena Vista, Florida
(UMDNJ)
17 The Breast
8 A.M. -2 P.M. — The Sheraton
Poste Inn, Cherry Hill
( Cooper Hospital/University
Medical Center)
17 Women’s Health Care
9 A.M. -4 P.M. — St. Peter’s
Medical Center, New Brunswick
(UMDNJ)
17 Subcutaneous Terbutaline
Pump Therapy for Recurrent
Preterm Labor
6:30-7:30 P.M. — Yardley Country
Club, Yardley
(Mercer Medical Center)
24 Ultrasound
9 A.M. -4 P.M. — St. Peter’s
Medical Center, New Brunswick
(UMDNJ)
ONCOLOGY
November
30 Breast Cancer: Risks and
Controversies
8:45 A.M. -4: 15 P.M. — Robert
Wood Johnson Medical School,
New Brunswick
(UMDNJ)
ORTHOPEDICS
October
26- 15th Annual New Jersey
27 Orthopaedic Symposium in
Conjunction with the 23rd
Annual Northeastern Mid-
Atlantic Orthopaedic Residents’
Conference
3:15 P.M. — Hyatt Regency,
New Brunswick
( AMNJ and New Jersey
Orthopaedic Society)
PSYCHIATRY
October
2 Psychiatry Grand Rounds
9 8:30-10 A.M. — Elizabeth General
16 Medical Center, Elizabeth
23 (Elizabeth General
30 Medical Center)
4 Biological Origins of Alcoholism
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
5 Annual Fall Meeting
6:30 P.M. — Hyatt Regency,
New Brunswick
(New Jersey Psychiatric
Association)
11 Cocaine Addiction: New
Directions in Treatment
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
18 Diagnosis and Treatment of
Nicotine Addiction
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
24 High Anxiety
All day — Carrier Foundation,
Belle Mead
( Carrier Foundation)
25 Early Office Recognition of
Depression Relating to Patient
Management
12 Noon-1 P.M. — Freehold Area
Hospital, Freehold
(AMNJ)
November
1 Research Update: Adolescence
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
6 Psychiatry Grand Rounds
13 8:30-10 A.M. — Elizabeth General
20 Medical Center, Elizabeth
27 (Elizabeth General
Medical Center)
7 Treatment Plan and Goal
Setting in Psychiatric Patients
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
8 Psychopathology as Predictor of
Treatment Outcome in
Alcoholics
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
14 Cocaine Express
All day — Carrier Foundation,
Belle Mead
( Carrier Foundation)
15 Partial Hospitalization and its
Psychotherapeutic Role
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
21 Early Office Recognition of
Depression
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
30 Treatment of Borderline
Personality Disorder with Self-
Destructive Behavior
10-11 A.M. — Marlboro Psychiatric
Hospital, Marlboro
(AMNJ)
RADIOLOGY
October
18 Radiology Meeting
7:30 P.M — Saint Barnabas
Medical Center, Livingston
(Radiology Society of
New Jersey/ AMNJ)
20 MRI Seminar
8 A.M. -5 P.M. — Hyatt Regency,
New Brunswick
(Radiological Society of
New Jersey)
November
15 Radiology Meeting
Saint Barnabas Medical Center,
Livingston
(Radiology Society of
New Jersey/ AMNJ)
SURGERY AND ITS SPECIALTIES
October
18 Surgical Grand Rounds
5-6 P.M. — Shore Memorial
Hospital, Somers Point
(Shore Memorial Hospital)
27- Cardiac Surgery
28 Bally’s Park Place Hotel &
Casino, Atlantic City
( Cooper Hospital/University
Medical Center)
November
7 Annual Meeting
9 A.M. -5 P.M. — Dover General
Hospital, Dover
( Society of Surgeons of
New Jersey)
7 Fall Scientific Meeting
All day — The Manor,
West Orange
(Vascular Society of New Jersey)
VOL. 87— NUMBER 9 SEPTEMBER 1990
745
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Acupuncture & Electro-Therapeutics
in Clinical Practice
New York State Boards of Medicine & Dentistry
25-hour accredited seminar & workshop on latest theories
and techniques of manual & electro-acupuncture, TENS &
simple non-invasive diagnostic methods (including
cardio-vascular, neuromuscular, central nervous systems &
"Bi-Digital O-Ring Test"), applicable towards 300-hour
requirement for certification to practice acupuncture, will be
given periodically for licensed clinicians (with or without
prior training) on 3-day weekends (Fri-Sun) of Sept.
21-23, and Dec. 14-16, 1990, at Milford Plaza Hotel, j
45th St. & 8th Ave., New York City.
The 6th Annual International Symposium on
Acupuncture & Electro-Therapeutics will be held at
Columbia University, School of International Affairs, 420
W. 118th St., N.Y. City, during October 25-28, 1990.
These meetings are co-sponsored by the International
College of Acupuncture & Electro-Therapeutics & its official
journal. Acupuncture & Electro-Therapeutics Research, The
International Journal (published by Pergamon Press &
indexed in 15 major indexing periodicals, including Index
Medicus), Heart Disease Res. Foundn, N Y Pain Center of
Long Island College Hospital (a teaching hospital of
SUNY-Health Science Center at Brooklyn); Electrical
Engineering Dept., Manhattan College; Nordic Medical
Acupuncture Society (Scandinavia); Schmerz Therapeutische
Kolloquium (West Germany); Japan Bi-Digital O-Ring Test
Assn; etc. The meetings are also eligible for AMA CME Cat.
I credit (about 40 credit-hours for the Symposium).
For information on meetings or submission or presen-
tation of papers, contact Symposium Chairman, Prof.
Y. Omura, M.D., Sc.D., 800 Riverside Drive (8-1) New
York, NY 10032 Tel: (212) 781-6262 (10am to 10pm 7
days a week) or (212) 928-0658, Co-chairman, Prof.
A.W. Cook, MD, (516) 877-1821, or Bro. Michael
Losco (212) 920-0162.
THE RADIOLOGICAL SOCIETY
OF NEW JERSEY
and
THE ACADEMY OF MEDICINE
OF NEW JERSEY
present
A ONE DAY SEMINAR
ON
CLINICAL MRI
SATURDAY. OCTOBER 20. 1990
8:00 A. M. -4:30 P.M.
at
THE HYATT REGENCY HOTEL
NEW BRUNSWICK, NEW JERSEY
(201) 873-1234
THE ACADEMY OF MEDICINE
OF NEW JERSEY
and
THE NEW JERSEY
ORTHOPAEDIC SOCIETY
present
THE FIFTEENTH ANNUAL
NEW JERSEY ORTHOPAEDIC
SYMPOSIUM
in conjunction with
THE TWENTY-THIRD ANNUAL
NORTHEASTERN-
MID-ATLANTIC ORTHOPAEDIC
RESIDENTS’ CONFERENCE
SATURDAY, OCTOBER 27, 1990
7:15 a.m.-3:35 p.m.
at
HYATI REGENCY
Albany Street
New Brunswick, New Jersey
Emergency Phone Number (201) 873-1234
The Complications/Resident’s Thesis Conference will be held
on FRIDAY, OCTOBER 26, 1990 at the Hyatt Regency from
2:00 p.m.-5:45 p.m. This will be followed by a cocktail hour and
dinner with spouses and faculty members at 6:00 p.m.
NEW JERSEY MEDICINE
746
John W. Alexander. Born in
Nashville, Tennessee, on March
14, 1919, and relocating to New
Jersey, John Wesley Alexander,
MD, died at the age of 71 in Or-
ange on June 3, 1990. Dr. Alex-
ander attended Meharry Medical
College, Nashville, Tennessee, and
received his medical degree in
1943. The following year, Dr. Alex-
ander received his New Jersey
medical license. Dr. Alexander in-
terned at the former Homer Phil-
lips Hospital, St. Louis, Missouri.
A pediatrician, Dr.' Alexander was
affiliated with: the Hospital Cen-
ter at Orange; Newark Beth Israel
Medical Center; and Children’s
Hospital of New Jersey, United
Hospitals Medical Center, New-
ark, that he helped to establish.
Dr. Alexander had private pedi-
atrics practices in Orange and
Newark. He served in the United
States Army Medical Corps for two
years. Dr. Alexander was a mem-
ber of our Essex County compo-
nent and of the American Medical
Association.
Lawrence G. Beisler. Word has
been received of the death of Law-
rence George Beisler, MD, of West-
field. Born in 1894 in Newark, Dr.
Beisler died on June 1, 1990, at the
age of 96. Dr. Beisler received his
medical degree from the University
of Pennsylvania School of Medi-
cine, Philadelphia, Pennsylvania,
in 1917 and his New Jersey medi-
cal license in 1919. A board-
certified surgeon, Dr. Beisler was
affiliated with Elizabeth General
Medical Center; with Saint Barna-
bas Medical Center, Livingston;
and with Rahway Hospital. Re-
tired since 1964, Dr. Beisler was a
member of the Society of Surgeons
of New Jersey, of the American
Medical Association, and of our
Union County component. In ad-
dition, Dr. Beisle was a fellow of
the American College of Surgeons.
Upon receiving his medical license,
Dr. Beisler served in the United
States Navy Medical Corps from
1917 to 1919, as a ship doctor and
surgeon on the USS Bushnell and
the USS Arizona.
Norman T. Crane. Plainfield
resident Norman Tompkins Crane,
MD, died April 5, 1990, at the age
of 88. Dr. Crane was born Septem-
ber 4, 1901 in Mahopac, New York.
Dr. Crane received his medical
degree from Columbia University
College of Physicians & Surgeons,
New York, in 1925 and his New
Jersey medical license the follow-
ing year. Dr. Crane completed his
internship at Muhlenberg Regional
Medical Center, Plainfield, and his
residency at Columbia-Presby-
terian Medical Center, New York.
Aside from his private pediatrics
practice, Dr. Crane was affiliated
with Muhlenberg Regional Medi-
cal Center and with Somerset
Medical Center, Somerville. In ad-
dition, Dr. Crane was a member of
the board of governors of Muhlen-
berg Regional Medical Center in
the late 1950s and was first vice-
president of the Plainfield Board of
Health. Dr. Crane served in the
United States Medical Corps dur-
ing World War II. During his
lengthy career, Dr. Crane was a
member of the American Medical
Association, and of our Union
County component.
Herbert Farber. An internist,
Herbert R. Farber, MD, died at the
age of 77. Born in Paterson on Feb-
ruary 3, 1913, Dr. Farber died May
29, 1990. Dr. Farber received his
medical degree from the University
of Virginia School of Medicine,
Charlottesville, Virginia, in 1940,
interning at Saint Joseph’s Hospi-
tal and Medical Center, Paterson,
and serving a residency at the for-
mer Baltimore City Hospitals, Bal-
timore, Maryland. In 1948, Dr.
Farber received his New Jersey
medical license. Dr. Farber had his
private medical practice in
Paterson for over 40 years and was
on the staff of Saint Joseph’s Hos-
pital and Medical Center. Dr.
Farber was a member of our
Passaic County component and of
the American Medical Association.
He served in the United States
Medical Corps from 1942 to 1946 as
captain.
Joseph W. Gamba. At the un-
timely age of 49, Joseph William
Gamba, MD, died on May 10,
1990. Born September 22, 1940, in
Newark, Dr. Gamba received his
medical degree from the University
of Pennsylvania School of Medi-
cine, Philadelphia, Pennsylvania,
in 1966, and his New Jersey and
Pennsylvania medical licenses the
following year. Dr. Gamba served
an internship at Delaware County
Memorial Hospital, Drexel Hill,
Pennsylvania, and a residency at
Newark Eye and Ear Infirmary. An
ophthalmologist, Dr. Gamba
maintained an office in Toms
River and was affiliated with Com-
munity Memorial Hospital, Toms
River, and with Newark Eye and
Ear Infirmary. Dr. Gamba was a
fellow of the American College of
Surgeons, of the American
Academy of Ophthalmology and
Otolaryngology, and of the Inter-
VOL. 87— NUMBER 9 SEPTEMBER 1990
747
national College of Surgeons. Dr.
Gamba also was a member of our
Ocean County component.
Arpad Gerard. After a long ill-
ness, North Brunswick resident
Arpad G. Gerard, MD, died on
May 21, 1990, at the age of 81. A
native of Budapest, Hungary, Dr.
Gerard was born May 14, 1909. Dr.
Gerard received his medical degree
from the University of Vienna,
Austria, in 1933 and his New Jer-
sey medical license in 1937. An in-
ternist, Dr. Gerard maintained a
private practice in Woodbridge for
many years. Dr. Gerard was af-
filiated with Raritan Bay Medical
Center, Perth Amboy. He was a
member of our Middlesex County
component and of the American
Medical Association.
John P. Lauricella. Word has
been received of the death of John
Patrick Lauricella, MD, of
Englewood Cliffs on May 19, 1990,
at the age of 61. Dr. Lauricella,
born in Fairview on August 7, 1928,
received his medical degree from
Jefferson Medical College, Phila-
delphia, in 1954. One year later, he
earned his New Jersey medical
license. A family practitioner, Dr.
Lauricella was affiliated with Holy
Name Hospital, Teaneck, and
Hackensack Medical Center. In
addition, Dr. Lauricella was a
professor of family practice at Uni-
versity of Medicine and Dentistry
of New Jersey, Newark. Dr.
Lauricella served in the United
States Army from 1955 to 1957. He
was a member of the American
Medical Association and of our
Bergen County component; and a
fellow of the American Academy of
Family Practice.
Arthur Mangelsdorff. Retired
since 1975, Arthur F. Mangels-
dorff, MD, died on June 11, 1990,
at the age of 85. Born in Union City
on August 15, 1904, Dr. Man-
gelsdorff received his medical
degree from Cornell University
Medical College, New York, in
1928. Two years later Dr. Man-
gelsdorff received his New Jersey
medical license. Dr. Mangelsdorff
practiced occupational medicine.
He worked with American
Cyanamid and later with Pruden-
tial. Dr. Mangelsdorff served in the
United States Army Reserves from
1928 to 1938 as first lieutenant. In
addition, Dr. Mangelsdorff was a
member of the American Medical
Association, of our Somerset Coun-
ty component, of the Industrial
Medical Association, of the New
Jersey Industrial Medical Associa-
tion, of the American Academy of
Occupational Medicine, and of the
Academy of Medicine of New Jer-
sey. Dr. Mangelsdorff also was a
medical consultant at Somerset
Medical Center, Somerville.
Michael J. Morrone. Born in
Philadelphia, Pennsylvania, on
November 21, 1906, Michael
James Morrone, MD, died on April
21, 1990, at the age of 83. Dr. Mor-
rone attended Hahnemann Medi-
cal College, Philadelphia, earning
his medical degree in 1935. Dr.
Morrone received his Pennsylvania
medical license in 1936 and his
New Jersey medical license in
1954. Dr. Morrone served an in-
ternship and a residency at St.
Agnes Medical Center, Philadel-
phia. A general practitioner, Dr.
Morrone practiced in Philadelphia
and was affiliated with St. Agnes
Medical Center and later relocated
to Vincentown and St. Petersburg,
Florida. In addition, Dr. Morrone
was employed by the Philadelphia
Naval Shipyard Medical Dis-
pensary and by the health depart-
ment of Florida. Dr. Morrone was
a member of our Burlington Coun-
ty component, of the American
Medical Association, and of the
Pennsylvania Medical Society.
Charles C. Polk. At the age of
95, Charles Carrington Polk, MD,
died May 18, 1990. Born in Bar-
rington on April 12, 1895, Dr. Polk
earned his medical degree from
Howard University College of
Medicine, Washington, DC, in
1921 and his New Jersey medical
license the following year. Dr. Polk
served an internship at the former i
Kansas City General Hospital,
Kansas City, Missouri. A retired
family practitioner, Dr. Polk was i
affiliated with St. Elizabeth Hos-
pital, Elizabeth; Rahway Hospital;
and Community Memorial Hospi-
tal, Toms River. Dr. Polk served in
the Infantry from 1917 to 1918. He
was a member of the American
Academy of General Practice, of
the American Medical Association,
of the Academy of Medicine of
Northern New Jersey, of our Union
County component, and of the
North Jersey Medical Society,
serving as secretary in 1939 and as
president in 1942. In addition, Dr.
Polk was involved in various com-
munity services.
Walter T. Rados. Born in New-
ark on June 14, 1926, ophthal-
mologist Walter Thomas Rados,
MD, died May 12, 1990, at the age
of 63. After earning his medical
degree from Jefferson Medical Col-
lege, Philadelphia, in 1951, Dr.
Rados received his New Jersey
medical license the following year.
Dr. Rados served his residency at
the Wilmer Institute at Johns
Hopkins University, Baltimore,
and his internship at Newark Beth
Israel Medical Center. From 1952
to 1954, he served in the military,
with a terminal rank of captain.
Dr. Rados had his practice in
Essex county for many years and
was affiliated with several Newark
hospitals: Newark Beth Israel
Medical Center, Newark Eye and
Ear Infirmary, and the University
of Medicine and Dentistry of New
Jersey-University Hospital. Dr.
Rados was a member of our Essex
county component and of the
American Medical Association; he
was a fellow of the American
Academy of Ophthalmology and
Otolaryngology, of the New Jersey
Academy of Ophthalmology, and
of the Academy of Medicine of
New Jersey.
748
NEW JERSEY MEDICINE
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
vision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statement accompany-
ing material offered to NEW JER-
SEY MEDICINE must contain the
following language and must be
signed by all authors.
“In consideration of NEW JER-
SEY MEDICINE taking action in
reviewing and editing my sub-
mission, the author(s) undersigned
hereby transfers, assigns, or other-
wise conveys all copyright own-
ership to the Medical Society of
New Jersey, in the event that such
work is published in NEW JER-
SEY MEDICINE.
Specifications. Submit two
manuscripts that must be type-
written and double-spaced on 8V2"
by 11" paper. Statistical methods
should be identified.
Authors are asked to seek clar-
ity, accuracy, and originality; at-
tention to details of grammar,
spelling, and typing are important.
The title page should include the
full name, degrees, and affiliations
of all authors, and the name and
address of the author to whom re-
print requests and correspondence
should be sent.
The author should submit a 30-
word abstract.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission must be
submitted.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote
with the first use of the generic
name. Proprietary names of de-
vices should be indicated by the
registration symbol — ®.
References should not exceed 35
citations except in review articles,
and should be cited consecutively
by numbers in parentheses at the
end of the sentence. The reference
list should be typewritten and
double-spaced on separate 8V2" by
11" sheets in numerical order. The
style of NEW JERSEY MEDI-
CINE for references is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
viewers and the authors will be
permitted, but authors will be in-
formed of the reviewers’ com-
ments. Galley proofs will be sub-
mitted to the author for correction.
Reprint Orders. Reprints may be
ordered after the author is notified
that the article has been selected
for a specific issue. A check for the
cost of reprints must accompany
that order.
Communications. All com-
munications should be sent to the
editor, NEW JERSEY MEDI-
CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
VOL. 87— NUMBER 9 SEPTEMBER 1990
751
Whom To Call At MSNJ Headquarters
Executive Director: Vincent A. Maressa
Address changes
Advertising (in NEW JERSEY MEDICINE)
AMA Delegation
Annual Meeting
Auxiliary, MSNJ
Biomedical Ethics
Blue Cross/Blue Shield
Board of Trustees
Continuing Medical Education
Council and Committee Appointments
Credentials
Delegates, MSNJ
DRG
Dues Payments: MSNJ and AMA
Eye Health Screening Program
Executive Committee
Financial Operations
HM Os/IPAs/PPOs
Hospital Medical Staff Relations
House of Delegates
JEMPAC
Judicial Council
Legal Services Plan
Legal Questions
Legislation
Liaison Reps to other organizations
Long-Range Planning Committee
Loss Prevention, Risk Management
Maternal and Newborn Record Books
Medical Assistants
Medical Education
Medical Services
Medical Student Loan Fund
Medicare/Medicaid
Membership Benefits
Membership Directory
Membership Records
Mental Health
NEW JERSEY MEDICINE
Nominating Committee
Officers of MSNJ
Peer Review Organization
Physicians’ Health Program
Professional Liability Insurance
Public Health
Public Relations
Resident Association
Resolutions for Annual Meeting
Senior Citizen Projects
Specialty Societies
Student Association
Subscriptions, NEW JERSEY MEDICINE
Third-Party Payor Complaints
Widows and Orphans Program
Women Membership
Joyce Guest
Joseph Cookson
Diana C. Gore
Eileen Pfeiffer
Margaret Fransckiewich
June O’Hare
Joseph C. Lucci
Diana C. Gore
Martin E. Johnson
Diana C. Gore
Mary Hamer
Eileen M. Pfeiffer
Vincent A. Maressa
Mary Hamer
Sue Arnone
Diana C. Gore
Arthur White
Joseph C. Lucci
Diana C. Gore
Diana C. Gore
June O’Hare
June O’Hare
Joseph C. Lucci
Vincent A. Maressa
June O’Hare
Diana C. Gore
Vincent A. Maressa
A. Ronald Rouse
Joyce Guest
Joseph C. Lucci
Martin E. Johnson
Joseph C. Lucci
Patricia Drakeford
Joseph C. Lucci
Joseph C. Lucci
Joyce Guest
Arthur White
Mary Hamer
Joseph C. Lucci
Geraldine Hutner
Diana C. Gore
Diana C. Gore
Vincent A. Maressa
David I. Canavan, MD
A. Ronald Rouse
Joseph C. Lucci
Martin E. Johnson
A. Ronald Rouse
Diana C. Gore
A. Ronald Rouse
Peggy Ann Johnson
A. Ronald Rouse
Nancy Propsner
Joseph C. Lucci
Joyce Guest
A. Ronald Rouse
752
NEW JERSEY MEDICINE
HEALTH ACCESS NEW JERSEY
In August, MSNJ leadership met with Governor Jim Florio and
presented him with the Society's position paper on health care,
Health Access New Jersey, featured on page 785. A summary of
the paper follows.
I. A plan proposed by the Medical Society of New Jersey to:
— Ensure that patients have the ability to choose physicians,
hospitals, and health care plans.
— Create incentives to make new technologies available.
— Sustain an excellent medical education system.
--Nurture high standards of conduct.
— Reduce the need for defensive medicine.
II. Action to solve the uncompensated care crisis:
— Expand access to care by raising Medicaid eligibility and
increasing payments to individual providers.
— Create a state-operated health insurance pool for small
businesses similar to the temporary disability program.
— Foster health insurance risk pools to cover those who cannot
obtain affordable insurance.
— Eliminate health insurers' pre-existing loss requirement and
waiting period for workers to gain coverage after changing
jobs.
III. Medicine's role in reducing costs;
— Encourage disease prevention and healthier lifestyles.
— Require physicians to practice with the highest ethical
standards .
— Develop standard practice parameters for all specialties.
IV. Government's role in reducing costs:
— Enact professional liability reforms to lessen the incidence
of defensive medicine.
--Eliminate the certificate of need requirement for diagnostic
equipment or raise the dollar threshold to $2 million.
— Redesign the hospital rate-setting program to make it
rational, understandable, and reflective of the active cost of
hospital care.
.
MSNJ
NEWSLETTER
BILLING FOR MEDICAL All physicians are reminded that except for the completion of health
INFORMATION TO insurance claim forms, they have the right to bill for providing patient
THIRD PARTIES information to third parties. The MSNJ Board of Trustees has notified
both the commissioner of labor and the commissioner of insurance of
this policy.
MEDICAL FEE SCHEDULES/AUTO INSURANCE PIP COVERAGE
The following letter was sent to Verice M. Mason, assistant commissioner, Legislative/Regulatory
Affairs, New Jersey State Department of Insurance from Vincent A. Maressa, MSNJ executive
director/general counsel:
This will respond to the notice published in the N.J. Register regarding proposed rule N.J.A.C.
11:3-29.
The Medical Society of New Jersey is opposed to the rule as an abridgement of constitutional
rights of physicians.
The Fair Automobile Insurance Reform Act and the Regulation being proposed pursuant
to it are illegal.
• The Legislature of New Jersey, by enacting the Fair Automobile Insurance Reform Act
of 1990 (FAIRA), has impaired the contractual rights of physicians to receive their usual
and customary fees as compensation for services provided those patients who have been
injured in an automobile accident in violation of the U.S. Constitution, Article I,
Section 10, Clause 1.
• The fee schedule proposed by the Department and the ban on balance billing as stated
in FAIRA ha”e impaired the contractual rights of physicians to receive their usual and
customary fees as compensation in violation of Article I, of the New Jersey State
Constitution.
• In denying physicians the opportunity to bill and collect from their patients, by mutual
agreement, the difference between their customary fees for the services they have
provided and the amount reimbursed through the fee schedule, the Legislature has
denied physicians access to lawful contractual remedies in violation of Article IV,
Section 7, Paragraph 3 of the New Jersey State Constitution.
• The ban on balance billing contained in FAIRA and repeated in the proposed regulation
violates Article IV, Section 7, Paragraph 4 of the New Jersey State Constitution since
the law embraces more than one object and those objects were not properly set forth
in the title of the act.
• The imposition of a cap on physician fees and a ban on contractual arrangements are
punitive and retaliatory in nature and are being applied to physicians to punish them
as a class for what the Legislature and the Department perceive as the wrongful
involvement of physicians in an automobile insurance system that encouraged mis-
management and the potential misuse of private and public monies. The cap on fees
and the ban on balance billings, in particular, are legislatively imposed punishments
intended to penalize physicians for their perceived past wrongdoing.
These punishments were imposed without lawful judicial process or procedural safe-
guard. The physicians of New Jersey were singled out, tried, convicted, and sentenced
by the Legislature for what is believed to be their part in bringing about the chaos
that was and is the New Jersey automobile insurance system. Article I, Section 10,
VOL. 87— NUMBER 10 OCTOBER 1990
767
MSNJ NEWSLETTER
Clause 1 of the U.S Constitution bans legislative determinations of guilt and imposi-
tions of punishment as bills of attainder.
• By singling out physicians and certain others, but not all professions, for disparate
treatment without rational basis, the Legislature and the Department are denying
physicians the equal protection required under the Fourteenth Amendment to the U.S
Constitution.
If FAIRA is constitutional, the proposed fee schedule is not.
• Since FAIRA imposes a ban on balance billing, any fee schedule used pursuant to it
must be comprehensive in scope both regarding all health professions and the services
they provide.
• The fee schedule proposed does not cover all services or specialties within the medical
profession commonly involved with services to automobile accident benefits.
• A significant number of health providers, other than physicians are mentioned in
FAIRA, but their services are not included in the proposed regulation.
If the proposed regulation is constitutional, it does not meet the statutory requirements
of FAIRA.
• In a number of instances, the reimbursement allowed is greater in Region I or II rather
than Region III. That is clearly unreasonable and does not comply with well-known
economic factors.
• The Legislature clearly intended that the fee schedule be specialty specific by region
unless less than 50 physicians of a given specialty were within that region. The proposed
schedule does not meet that standard.
• The Legislature clearly mandated that the schedule must pay at the 75th percentile.
The schedule has a number of procedures and reimbursements that do not meet that
standard as it is applied by the federal government under Medicare, i.e. CPT codes
20670, 23500, and 23650.
• The fee schedule does not cover all procedures intended by the statute.
• The fee schedule does not cover the services of all professions intended by the Legis-
lature and named in the statute.
• The fee schedule does not meet the standard of a rational relationship to the act adopted
by the Legislature in terms of scope, consistency, and quality.
• The fee schedule cannot be rationally applied to the services rendered to the critically
injured patients at trauma centers.
• The fee schedule treatment of multiple procedure situations can only be reasonable
when applied to routine elective surgery and not to emergent or critical situations.
• The fee schedule does not properly reimburse for comprehensive examinations, consul-
tations, and followup visits.
Regardless of the overall constitutionality of FAIRA, it is obvious that the proposed schedule
does not fairly represent compliance with FAIRA.
I again urge the Department to invoke a broad-based panel of experts to assist in the development
of a fee schedule that can meet the statutory standard. As we have previously offered our
assistance, we do so again.
MEDICAL WASTE
PROGRAM
REGISTRATION
REQUIREMENTS
Regulation N.J.A.C. 7:26-3A.8(2) requires anyone who generates regu-
lated medical waste in New Jersey must register with the New Jersey
State Department of Environmental Protection, Division of Solid Waste
Management, as a regulated medical waste generator and pay the ap-
propriate fee. The second registration year for generators extends from
July 22, 1990, through July 21, 1991. All generators who have failed to
register for the 1989-1990 year will be responsible for registering for that
year and the 1990-1991 registration year. Failure to do so will subject
the generator to potential fines. All generators are assigned identification
numbers upon registration. Generators of regulated medical waste must
file an annual report as specified by N.J.A.C. 7:26-3A. 21(h). The initial
768
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
annual generator report covers the period from June 22, 1989, to June
21, 1990. The report forms are to be completed and returned to the
Bureau of Special Waste Planning within ten days of receipt by the
generator. A copy of the revised daily/monthly log form and instructions
will be included with the report form mailing to generators. Use the new
form upon receipt. A hotline number, 609/530-8599, will be available to
assist generators of medical waste with their questions concerning com-
pletion of the annual report.
PHYSICIAN ASSISTANTS
The following are the comments of Herbert J. Stern, Esquire, legal counsel to MSNJ regarding
proposed new rule N.J.A.C. 13:35-6.15. The Medical Society of New Jersey and its members
oppose N.J.A.C. 13:35-6.15 for the following reasons:
1. Promulgation of the regulation amounts to creating a new class of physicians, an act
that exceeds this Board’s statutory authority under N.J.S.A. 45:9-1, et seq.
2. The Legislature by considering and rejecting bills to authorize physician assistants has
signalled its direct opposition to the regulation; and
3. The regulation itself is poorly drawn because it illegally delegates the power to authorize
nondoctors to practice medicine to individual hospitals.
Since the early 1970s, states have wrestled with the issue of permitting nonlicensed physicians
to perform medical procedures. There has been a great deal of debate about this subject. I do
not intend to address in detail whether the proposed rule will be of any value to the public.
I will leave that to the medical professionals who will testify here today. Instead, I will focus
on the legal deficiencies presented by the proposed rule being considered by the Board.
The first issue I would like to address is this Board’s lack of authority to take the proposed
action. An administrative action is void if it does not fall within the boundaries of the legislative
delegation involved, e.g. Swede versus City of Clifton, 22 N.J. 303, 312 (1956). Administrative
action is of necessity restrained by the declared policy and spirit of the statute and the criteria
and standards therein laid down, for a grant not thus confined would constitute a delegation
of essential legislative power in contravention of constitutional limitations, Abelson’s, Inc. versus
N.J. State Board of Optometry, 5 N.J. 412, 423 (1950). “Rules and regulations [as promulgated
by an administrative agency] cannot subvert or enlarge upon the statutory policy . . . Id. at
424. This is precisely what the Board would be doing should it choose to enact the proposed
regulation.
This Board owes its existence to the Medical Practice Act, N.J.S.A. 45:9-1 et seq. This act of
the Legislature not only created the Board and defined its authority and powers, it also defined
the practice of medicine (N.J.S.A. 45:9-5.1 and N.J.S.A. 45:9-18) and declared the practice of
medicine without a license from this Board to be illegal (N.J.S.A. 45:9-22). The letter and intent
of the Medical Practice Act was to create a regulatory scheme to protect the public that would
require persons in New Jersey to satisfy certain stringent requirements including four years of
an accredited medical school and certain written examinations before permitting them to prac-
tice medicine. This Board was created to monitor these persons and to ensure that the qualifi-
cations specified by the Legislature are met. This Board does not have the authority to change
those qualifications that were established by statute, e.g., N.J.S.A. (45:9-15 through 45:9-6).
Accordingly, this Board has discretion to regulate the practice of medicine including establish-
ment of substantive standards for medical practice, e.g. Brodie versus State Board of Medical
Examiners, 177 N.J. Super. 523 (App. Div. 1981).
However, there is a substantial distinction between regulation and legislation. The proposed
regulation constitutes a direct subversion of this Board’s enabling legislation. It creates an entire
new class of practitioners of medicine, unlicensed practitioners who lack the legislatively man-
dated qualifications. The Board concedes that, under this regulation, physician assistants will
be authorized to perform medical tasks including, among others, examinations of patients and
assisting physicians in surgery. Such acts would directly violate N.J.S.A. 45:9-22 that makes
it illegal to practice medicine without meeting the requirements, including licensing, established
OL. 87— NUMBER 10 OCTOBER 1990
769
MSNJ NEWSLETTER
by the Legislature. The Legislature has clearly set forth in N.J.S.A. 45:9-21 all persons exempted
from this prohibition. Physician assistants were not excepted by the Legislature and are therefore
subject to the prohibitions of N.J.S.A. 45:9-22.
Since the Board was not given the authority to rewrite or amend N.J.S.A. 45:9-21 and 45:9-22,
it does not have the authority to promulgate this regulation.
But we need not rely solely upon the text of the Medical Practice Act to determine the Legis-
lature’s intent in this instance. The Legislature has on a number of occasions specifically
considered legislation to authorize the use of physician assistants and rejected such legislation.
In particular:
1. On June 14, 1971, A-2500 was introduced to grant this Board the authority to develop
and approve programs for the training of syniatrists and to approve those individuals to perform
certain specified medical services under the supervision of a duly licensed physician or surgeon.
The bill never was brought to a vote and did not pass.
2. Again, on April 12, 1976, S-1354 to authorize the use of physician assistants was in-
troduced and referred to the Committee on Labor Industry and Professions. The bill never was
brought to a vote and did not pass.
3. On May 1, 1978, A-1314 to authorize the use of physician assistants was introduced and
assigned to the Committee on Commerce Industry and Professions. The bill never was brought
to a vote and did not pass.
4. On May 15, 1978, A- 1387 was introduced and referred to the Committee on Institutions
Health and Welfare. The bill was reported out of Committee on February 13, 1979, amended
but never was voted upon and did not pass.
5. On May 25, 1978, S- 1 192 to authorize physician assistants was introduced and assigned
to the Committee on Labor Industry and Professions. It never was brought to vote and did not
pass.
6. On June 12, 1980, A- 1753 to authorize physician assistants was introduced and referred
to the Committee on Institutions, Health and Welfare. The bill was reported out of committee
on October 6, 1980, given a second reading and amended. It never was brought to a vote and
did not pass.
7. On May 10, 1982, S-1349 to authorize the use of physician assistants in cardiovascular
surgery was introduced and assigned to the Committee on Labor Industry and Professions. It
was reported out of Committee on February 9, 1983, given a second reading, and amended. On
May 23, 1983, it was returned to second reading and amended again. It was not brought to vote
and it did not pass.
8. On November 19, 1984, A-2889 to authorize the use of physician assistants was introduced
and referred to the Committee on Health and Human Services. It never was brought to vote
and did not pass.
Moreover, the Legislature has specifically considered whether this Board should be permitted
to authorize physician assistants. S-1591 to prohibit the regulatory authorization of physician
assistants was prefiled in 1988, assigned to the Committee of Health and Human Services,
amended on February 1, 1988, released from the Committee with a second reading and passed
the Assembly on February 18, 1988. The bill was received in the Senate, but never was brought
to a vote. Currently, a similar bill, A-3529, is pending in the Legislature.
As the foregoing legislative history demonstrates, the Legislature’s clear intent was to reserve
the authorization of physician assistants to the Legislature and not to delegate this authority
to this Board. Moreover, the Legislature on eight separate occasions has been presented with
the opportunity to authorize the use of physician assistants and has chosen not to do so, thereby
demonstrating its intent. One half of the Legislature has directly demonstrated its intent that
the Board not be permitted to enact such regulations. Such a clearcut and overwhelming
demonstration of the legislative intent with respect to physician assistants demonstrates that
this Board would be exceeding its authority and jurisdiction by considering and issuing the
proposed regulations or any regulations that seek to authorize physician assistants. The more
prudent and indeed the lawful course would be to wait for the Legislature to pass such legislation
clearly authorizing the Board to promulgate these regulations and/or directly authorizing phy-
sician assistants. The correctness of this course also may be seen from the fact that every state
770
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
in the country that has authorized the use of physician assistants with the exception of Missis-
sippi has done so through legislative action rather than through Board regulations.
As an aside, it should be noted that available data reveal that approximately 25 physician
assistants per year are graduated in New Jersey. Under the proposed regulations, approximately
160 health facilities exist and could qualify to employ physician assistants. This would mean
it would take at least seven years before even one physician assistant was placed in each of
the qualified facilities. Thus, the impact and value of such physician assistants in providing
medical services to New Jersey residents would be negligible at best.
In addition to the fact that the Board has no authority to issue this regulation, the regulation
itself illegally delegates to hospitals the authority to authorize nonlicensed persons to practice
medicine. This Board’s regulation N.J.A.C. 13:35-4.1 requires an assisting surgeon to be present
at every “major” surgical procedure. However, the Board never has defined what is meant by
the term “major” and has left such determinations to the individual hospitals. As a result,
various hospitals in New Jersey define major surgical procedures differently.
Regulation 13:35-4.1 in itself is legally flawed since it unlawfully delegates the Board’s authority
to determine when the use of an assisting surgeon is required. However, this flaw is compounded
in the current legislation. Under proposed rule 13:35-6.15, paragraph D(7), a physician may
delegate to a physician assistant the task of “assisting a supervising surgeon in the operating
room when a qualified first assistant surgeon is not required pursuant to N.J.A.C. 13:35-4.1.”
Since the Board has delegated the determination of when an assisting surgeon is required to
the individual hospitals, this provision delegates to the hospital the authority and ability to
authorize physician assistants to practice medicine and to independently determine which
operations a physician assistant may assist in. It is unquestionable that the Legislature did not
intend and did not authorize this Board to delegate the authority to individual hospitals to
determine on a case-by-case basis when physician assistants may practice medicine.
Given the legislative history rejecting physician assistants, the legal deficiencies of the proposed
regulation and the negligible effect this rule would have on the provision of medical services
to the public, the Medical Society of New Jersey respectfully submits that the Board should
not enact proposed Rule N.J.A.C. 13:35-6.15. Such action would be an unauthorized “extra
jurisdictional administrative act” under Swede versus City of Clifton and would subvert not
only this Board’s enabling legislation but the clear legislative intent rejecting such action.
HEALTH CARE POLICY
STUDY COMMISSION
ADDRESSED
The Assembly Health Care Policy Study Commission was called upon
to devise ways to make medical insurance more available to New Jersey
residents. A national representative of the Communications Workers of
America addressed the Commission and stated that everyone is entitled
to health care: “This is the only industrialized country that doesn’t have
some sort of health plan that gives people a right to guaranteed health
care.” More than 800,000 people in New Jersey are without some kind
of health insurance coverage although more than half are employed
according to Assembly statistics.
NJHA REQUESTS
MAJOR CHANGES
TO SYSTEMS
The New Jersey Hospital Association has presented a report to the
Governor’s Commission on Health Care Costs that includes the request
for the development of a new hospital payment system. NJHA wants
the new system to be less complex, more prospective, and more timely
that would limit the number of appeals. NJHA has called for the
elimination of the current “confusing” patient billing system. Currently,
inpatients are billed based on averages for 600 different medical
diagnoses. It was reported that NJHA called for patient bills based on
charges incurred. Another recommendation in the report calls for a
statewide payroll tax on employers and employees to finance a man-
datory health insurance plan for all workers in the state.
FIN I “The test of good manners is to be able to put up pleasantly with bad
ones.”
VOL. 87— NUMBER 10 OCTOBER 1990
771
Greenberg Margolis
A PROFESSIONAL CORPORATION
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MR. GLICKMAN IS A FORMER ADMINISTRATIVE LAW
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NEW JERSEY MEDICINE
STANDARD OF CARE:
THE HONEST ERROR
OF JUDGMENT RULE
PROFESSIONAL
LI Ail LIT Y
In malpractice cases, the performance of physicians traditionally has
been judged according to the customs of the profession. The reason-
ableness of a physician’s conduct usually is determined by the conduct
of other reasonable and prudent physicians in similar circumstances.1
Expert testimony is typically required to establish the standard of care
as well as a breach of that standard. This approach suggests that the
standard in malpractice cases is objective and scientific. It also suggests
that there is a correct procedure or treatment in each case. In fact,
however, the practice of medicine is rife with uncertainty. Rarely is there
only one correct approach to or treatment of a particular medical con-
dition. In this regard, it is often said that the practice of medicine is
more an art than a science.
As the practice of medicine develops and changes, the applicable stan-
dards of care have been modified to reflect these changes. Some modi-
fications of the standard of care take into account the artistic side of
medical practice. These modifications permit courts to apply a more
subjective standard of care. For example, several courts have held that
physicians are not liable for mere “honest errors of judgment.”2 The
honest error of judgment rule amounts to a recognition of the problem
of medical uncertainty. Its purpose is to protect a physician from liability
for a mistake in judgment where there is more than one reasonable course
of action available under the circumstances. While some courts have
recently upheld the inclusion of an honest error of judgment instruction,
other courts have held it to be improper.
In Ouellette by Ouellette versus Subak,3 the Minnesota Supreme Court
reaffirmed the vitality of the honest error of judgment rule.3 This case
arose out of a birth-related neurological injury. The plaintiffs alleged
that the defendants had failed to properly manage the pregnancy by
permitting a prolonged pregnancy, failing to timely induce labor, and
failing to recognize signs of fetal distress. The evidence revealed that
the physicians were uncertain as to the estimated due date of the baby.
The trial court refused to give the honest error of judgment instruction
requested by the defense despite the fact that the rule had been rec-
ognized in Minnesota since 1907. In discussing the reasons for the honest
error of judgment rule the Ouellette court quoted from Staloch versus
Holm:4
In an ordinary action for negligence, that a man has acted ac-
cording to his best judgment is no defense. The standard of
careful conduct is not the opinion of the individual, but is the
conduct of an ordinarily prudent man under the circumstances
.... With respect to matters resting upon pure theory, judg-
ment, and opinion, however, there is a generally recognized
variation from this sound general principle.
Cases of malpractice may be within the exception. A physician
entitled to practice his profession, possessing the requisite quali-
fications, and applying his skill and judgment with due care, is
■i
VOL. 87— NUMBER 10 OCTOBER 1990
773
PROFESSIONAL LIABILITY
not ordinarily liable for damages consequent upon an honest
mistake or an error of judgment in making a diagnosis, in
prescribing treatment, or in determining upon an operation,
where there is reasonable doubt to the nature of the physical
conditions involved or as to what should have been done, in
accordance with recognized authority and good current practice.
Most professional men are retained or employed in order that
they may give the benefit of their peculiar and individual judg-
ment and skill. A lawyer, for example, does not contract to win
a lawsuit, but to give his best opinion and ability. He has never
been held to liability in damages for a failure to determine
disputed questions of law in accordance with their final decision
by courts of appeal. It would be just as unreasonable to hold
a physician responsible for an honest error of judgment on so
uncertain problems as are presented in surgery and medicine.5
While reaffirming the validity of the reasons for the rule, the court
nonetheless expressed concern over the subjective nature of words such
as “honest.”6 In elaborating on the need to protect professionals from
liability for non-negligent errors in judgment, the court stated:
If there are two methods of treatment for a particular medical
condition, both accepted by the medical profession, then it is
a matter of professional opinion or judgment which is best, and
the doctor’s choice of either is, ordinarily, not negligence. But
what if the two methods of treat ment depend on different factual
bases, i.e. if one method is acceptable, if the facts are one way
and the other method is acceptable if the facts are another way,
and neither method is acceptable for both sets of facts? Then
the doctor who fails to use reasonable care to ascertain the facts
may be negligent if he or she does not choose the accepted
method or treatment for the factual condition a reasonably pru-
dent doctor would have ascertained.
But what if, at the time a decision must be made, all the
requisite facts, even with the exercise of reasonable care, cannot
be ascertained and either of two methods of treatment reason-
ably appears acceptable? At times a doctor may have to make
a decision on the basis of incomplete, unclear, or tentative data.
Obviously, this creates a situation that leaves a doctor vulner-
able to hindsight and second guessing if the result is bad. There-
fore, the court in Staloch said a doctor should not ordinarily be
liable for an honest error of judgment ‘where there is reasonable
doubt’ as to the nature of the physical conditions involved or
as to what should have been done.
In conclusion, the Ouellette court held that the case should be remanded
for a new trial because of the trial court’s failure to give an appropriate
instruction on the problem of medical uncertainty. Instead of the tra-
ditional “honest error of judgment” instruction, it proposed the following
instruction:
A doctor is not negligent simply because his or her efforts prove
unsuccessful. The fact a doctor may have chosen a method of
treatment that later proves unsuccessful is not negligence if the
treatment chosen was an accepted treatment on the basis of the
information available to the doctor at the time a choice had to
be made; a doctor must, however, use reasonable care to obtain
the information needed to exercise his or her professional judg-
774
NEW JERSEY MEDICINE
PROFESSIONAL LIABILITY
ment, and an unsuccessful method of treatment chosen because
of a failure to use such reasonable care would be negligence.8
The Iowa Supreme Court also recently reaffirmed the propriety of giving
an honest error in judgment instruction.9 Other cases, however, have held
that the inclusion of an error in judgment instruction is improper.10 For
example, in Rogers versus Meridian Park Hospital,11 the Oregon Su-
preme Court held that the trial court erred in giving an honest error of
judgment instruction. The court stated:
(1) A physician is charged with applying without error those
principles and learnings that are settled and agreed upon by all
members of the medical profession. (2) In some cases, there may
be reasonable differences of opinion among members of the
medical profession as to the nature of the patient’s condition or
the proper course of treatment. (3) When there is such a dif-
ference of opinion, the physician must exercise reasonable judg-
ment. (4) A physician is liable for an error of judgment if the
physician fails to act with reasonable care and skill in exercising
that judgment. (5) A physician is not liable for an error in
judgment if the physician acts with reasonable care and skill in
exercising such judgment.12
The plaintiff in Rogers had abdominal surgery. Afterwards he regurgi-
tated and aspirated matter from his stomach. Subsequently, the plaintiff
suffered related permanent lung and kidney damages and filed this
action to recover for those injuries. Expert testimony established that
the endotracheal tube should be used to assist breathing and prevent
aspiration of stomach material into the lungs. However, there was a
difference of opinion as to when this tube should be removed from a
patient. The plaintiff s expert testified that the defendant prematurely
removed the tube. The defendant’s experts testified that the removal
of the plaintiffs tube was timely and was an appropriate medical
alternative. In addition, the experts also differed over the appropriate
position in which to place a patient during recovery in order to reduce
the risk of aspiration.
The Rogers court noted that the honest error of judgment rule is “derived
in part from the notion that a doctor does not promise a cure and that
an untoward result might not be a result of negligence.”13 It also derived
in part “from the recognition that, if there is more than one acceptable
treatment option, then the selection of one of them is not negligence.”14
Nonetheless, it noted that courts in several other jurisdictions had re-
cently disapproved of the use of an error of judgment instruction. It
concluded that the instruction was “unduly confusing” and noted that
the “fundamental issue” in malpractice cases is “whether the defendant
breached the standard of care and caused injury to the plaintiff.”15
In Leazer versus Kiefer,16 the Idaho Court of Appeals followed the Rogers
decision and held the instruction to be improper. The court noted that
the Oregon court had recognized a growing trend of decisions that disap-
proved of such instructions. It held that the honest error of judgment
instruction obscured the physician’s obligation to meet the standard of
care, skill, and diligence required by law. Moreover, it could be inter-
preted as absolving a physician from liability if he exercised his best
judgment despite the fact that he was negligent. The Leazer court con-
cluded that the honest error of judgment rule should not be used as a
substitute for the requirement of reasonable care. (Reprinted from Medi-
cal Malpractice Reports, Albany, NY, July 1990, Vol. 3, No. 12.). Foot-
notes will be furnished upon request. □
VOL. 87— NUMBER 10 OCTOBER 1990
775
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Mary Ann Hamburger offers you many services
ranging from a one-time survey to a continuing service
in which she will make regular visits to your office
to help with any pending problems.
74 HUDSON AVENUE
MAPLEWOOD, NEW JERSEY 07040
? 763-7394
v
MSNJ-Endorsed Health Care Plans
Blue Cross/Blue Shield/Major Medical
Comprehensive Major Medical
Dental Insurance
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For specially designed benefits, more competitive
premium rates and professional claims service,
take two (or more) and call us in the morning:
jfSN j.
(DONALD E SMITH
The Insurance Solutions People
(609)895-1616
The Physician's Cure For Insurance Headaches.
776
NEW JERSEY MEDICINE
mm EDITOR’S
E& DESK
A TIME OF “It has become more and more apparent that government, in all its
LOWERING ramifications, is the number one problem to the medical profession.
EXPECTATIONS There is a certain amount of irony in this situation. In all the polls the
physician is considered a member of the most honorable and respected
occupation or profession. Conversely, when the question is asked, ‘What
are the three greatest lies?’ — regardless of what any two of the answers
may be — the third lie always is, ‘I’m from the government and I’m here
to help you.’ ... All three branches of government participate in the
process — the courts to some extent, and the legislative and executive
branches to the point of rebellion.”1
Today, we have great concerns about the Governor’s Commission on
Health Care Costs. We had pointed out earlier that MSNJ had no input
into the composition of this special committee. It became even more
apparent that MSNJ would have equally deficient input of information
to the executive branch — information that could be used to formulate
policy based on reason, logic, and facts. MSNJ’s Committees on Un-
compensated Care and on Patient Care for the Under-Insured have been
stymied by the indifference of the New Jersey State Department of
Health, and the Advisory Board of the Uncompensated Care Trust Fund
was mothballed pending preliminary reports of the Commission.
The MSNJ Board of Trustees, taking a cue from the AMA, presented
a new and innovative program to the governor: Health Access New
Jersey. The full text of the report appears on page 785 and a summary
appears in the “Newswatch” section. We would like to tell you that these
efforts of MSNJ and its Board have borne fruit; we cannot. The presen-
tation was pruned, and we expect a skimpy harvest.
A recent survey published by Money magazine listed 80 sites in the
United States that are more desirable as residences than is New Jersey.
Monmouth and Ocean counties, listed 32nd last year, now head the New
Jersey listing in 81st place. Middlesex, Somerset, and Hunterdon coun-
ties fell from 8th place to 105th place. Bergen and Passaic counties
dropped from 28th place to 206th place. We can joke about the elevation
of Duluth — average January temperature of 0 to 20 degrees — from 51st
to 21st slot. We can rail about Governor Jim Florio and his record setting,
in both speed and in size, tax bite. But the precipitous fall in the
rankings is there for all to see and the high per capita income of New
Jersey citizens will not erase it. Many economists ascribe the denigration
to crowding and to our economy — dropping incomes and worsening costs
of living. The Pocono Mountains real estate brokers are reaping some
of the benefits we are losing, as New Jerseyans look for economic relief
by moving across the Delaware.
(Are you listening, Governor Jim?)
The Northwestern Life Insurance Company released a different type of
list— its latest, state-by-state, health rankings. These rankings were
based on five factors: lifestyle, access, disability, disease, and mortality.
VOL. 87-NUMBER 10 OCTOBER 1990
777
EDITOR’S DESK
“Lifestyle” included smoking, crime, career, and level of education.
“Access” evaluated such things as unemployment rates, prenatal care,
and shortage areas. “Disability” had two components, relating to the
proportion of those disabled and to the number of physician visits.
“Disease” meant cancer, heart disease, and infectious disease, including
AIDS. And “mortality” was age and rate adjusted, weighted toward
younger age groups. Overall, New Jersey ranked 16th of 50 states. It was
41st in “diseases”; 21st in “disability”; 19th in “mortality” and in
“lifestyle”; and 4th in “access.” Interestingly, despite all the brouhaha
about the underinsured, the sick and injured in New Jersey have the
fourth best access to care in the entire country — a tribute to the caring
and professional New Jersey physician, and yet, still not good enough;
hence, Health Access New Jersey. The other four criteria in the North-
western survey are societal in nature and cannot be solved by further
restrictions on the health care professional. We hope, but are not too
hopeful, that the Commission and its sponsor also will consider this
health survey, New Jersey’s ranking, and Health Access New Jersey.
(Are you listening, Governor Jim?)
“It is upsetting to have lesser skilled paraprofessionals raised to levels
unwarranted by their training. ... It is unnerving for Big Brother to be
looking over one’s shoulder and monitoring even the most inconsequen-
tial of physician activities. It is unfair for bureaucrats and legislators
to attempt to fix physician reimbursement as add-ons to regulations and
statutes. ... It is foolhardy for government to alter radically the pay-
ment for health care in favor of an untried system. . . . And, it is
intolerable for all of these constricting and restricting actions to be
promulgated and instituted without the proper involvement of the medi-
cal profession. Yet, such is the case. Two hundred years ago this country
heard the battle slogan, ‘Taxation without representation is tyranny.’
Perhaps it is time for us to renew that slogan, with or without another
tea party.”1
Are you listening, Governor Jim? Or is it already too late for you and
for our patients?
“No man is good enough to govern another man without
the other’s consent.” Abraham Lincoln, 1854
1. Slobodien HD: Time of high adventure. J Med Soc NJ 80:417, 1983.
778
NEW JERSEY MEDICINE
BOOK
REVIEWS
CORE TEXTBOOK OF Robert Kaye, MD, Frank A. Oski, MD, Lewis A. Barness, MD (eds).
PEDIATRICS Philadelphia, PA, J.B. Lippincott Company, 1988. The third edition of
Core Textbook of Pediatrics by Kaye, Oski, and Barness was designed
for the medical student, but may be an appropriate companion for the
pediatric and family practice junior house officer as well.
The contributing authors represent pediatric subspecialties from a wide
range of prestigious teaching institutions. The book is organized into
both systems and pediatric problems. The emphasis is on basic
pathology, pathophysiology, and management of the most common pedi-
atric problems. Diagrams, charts, and algorithms are plentiful and are
very useful, especially in the teaching of differential diagnosis. Practical
considerations in management will serve house staff quite well.
A few chapters stand out as especially practical: “Dehydration and Fluid
Replacement” coauthored by Curran and Barness, provides a step-by-
step approach to fluid management by using actual cases; Tunnessen’s
chapter on enuresis is short and excellent; and Honig’s chapter on skin
is very complete in describing common skin disorders, but fails to
provide management strategies to make it useful to students or house
officers. (Photographs also would be quite useful in this chapter since
much of what medical students and pediatric residents see in pediatric
clinics are the common dermatoses of childhood.)
The bibliographies at the end of each chapter are short. There could be
more current references to encourage pediatric residents to review the
literature. It should be noted, however, that the synopsis provided for
each reference is an excellent tool for the reader.
Baker’s chapter, “Mental Retardation,” and Oski’s chapter, “The Dying
Child,” are superb additions to an introductory text. The topics are
handled well and introduce these difficult subjects often avoided by
house staff. Julia McMillan’s chapter, “Principles of Antimicrobial
Therapy,” has a concisely organized chart matching organisms and anti-
biotics of the most important childhood infections.
Overall, this is a very good introductory textbook for pediatric junior
house staff and medical students. It is well organized, easy to read, and
an excellent support for core lectures given in an academic setting. In
a world of expensive texts, this is a good buy for the price of $30.75.
□ Jane Ellen Aronson, DO
CORONARY Sheldon Goldberg, MD. The objective of this book is to provide a com-
ANGIOPLASTY prehensive understanding of percutaneous transluminal coronary
angioplasty (PTCA). There are 26 contributors from 13 university medi-
cal centers. The contents are divided into three parts. Part one reviews
developmental background, technique, adjunctive pharmacologic treat-
ment, and protection of ischemic myocardium during PTCA. Part two
discusses PTCA in specific clinical populations including multivessel
coronary artery disease following coronary artery bypass surgery, un-
stable angina, acute myocardial infarction, vasospastic angina, total
VOL. 87— NUMBER 10 OCTOBER 1990
781
BOOK REVIEWS
coronary artery occlusion, and in the high-risk patient. A chapter on
peripheral and coronary applications of laser angioplasty is included.
Part three deals with the complications and results of PTCA. There are
excellent discussions on how best to monitor the post-PTCA patient and
on the continued high incidence of restenosis. The last chapter in the
book deals with the issue of PTCA versus coronary bypass surgery. The
authors of this chapter are surgeons, but present a very balanced view-
point on clinical decision making for various subsets of patients along
with multiple citations to support their conclusions. Missing from this
excellent chapter is any discussion referable to the significant group of
patients who may require multiple diagnostic and PTCA procedures over
the same time period that a single left internal mammary artery graft
to the left anterior descending coronary artery with or without an ad-
ditional single vein graft to another vessel (single or two-vessel CAD)
would have lasted. Even if the economic factors still were to favor PTCA,
does one defend the multiple assaults upon the psyche and emotional
well-being of the patient compared with a single surgical procedure and
recovery? Will newer procedures such as lasers, stents, cutters, drills,
or grinders provide greater long-term success rates? On the technical
side, the book is very readable. There is a large bibliography demonstrat-
ing the broad base of knowledge to support the stated facts and opinions.
The illustrations are of high quality with good reproductions. Legends
for figures and tables are properly supportive. I highly recommend this
book for anyone wishing to review the subject of PTCA and its current
role in clinical medicine. □ Robert M. MacMillan, MD
JI Gallin, IM Goldstein, RO Snyderman ( eds ). New York, NY, Raven
Press, 1988. This 1,000-page text is solely dedicated to the advances in
the understanding of inflammation as the predominant problem as-
sociated with many clinical syndromes seen in the daily practice of
physicians. Obviously, “at the bottom” of any inflammatory reaction
are the interactions of the immune system and the mediators they release
that can act as specialized hormones on the immune system itself or
other organs, i.e. cytokines, or various agents that interact with other
organ systems, e.g. leukotrienes, prostaglandins, histamines. The editors
have gathered the experience of an excellent group of clinician-scientists
in order to deliver the expanse of information available. Of special
interest is the section devoted to clinical correlates and specific entities
that now are recognized as inflammatory, e.g. asthma, adult respiratory
distress syndrome, vasculitis. In addition, a separate section has been
dedicated to the pharmacologic modulation of inflammation that is an
excellent resource for individuals searching for a better understanding
of this area. □ Leonard Bielory, MD
Jerrold Mink, MD. New York, NY, Raven Press, 1990. The contributors
to this book succeed in their goal of presenting a comprehensive
musculoskeletal magnetic resonance overview. The volume is organized
in a text-atlas format, with liberal use of scans and extensive discussions.
The first section illustrates the physical basis of magnetic resonance
scanning. The remainder of the text addresses the musculoskeletal sys-
tem, including the spine, shoulder, knee, wrist, foot, and tempo-
romandibular joint. The beginning of each chapter includes a technical
treatment with attention to patient positioning and scanning pa-
rameters. The case studies that follow contain history, scan inter-
pretation, and discussion. The images are of a high quality with ample
use of plain films and computed tomography scans. Overall, the con-
tributors should be commended for constructing a well-written, educa-
tional text with state-of-the-art scans. □ Neil B. Horner, MD
INFLAMMATION: BASIC
PRINCIPLES AND
CLINICAL CORRELATES
MRI OF THE
MUSCULOSKELETAL
SYSTEM.
A TEACHING FILE
782
NEW JERSEY MEDICINE
Health Access
New Jersey
Position of the Medical Society of New Jersey
New Jersey is the most densely populated state in the nation. The standard of income
and sophistication of our residents ranks among the top three states. Our health care
system is among the finest. We have over 100 acute care hospitals, and our hospitals
average over 300 acute care beds. For the most part, access to care is equitable throughout the
state.
The University of Medicine and Dentistry of New Jersey is a nationally recognized medical
school. Most areas of our state are within 30 minutes drive of major hospital and physician
facilities. New Jersey residents have a variety of choices and immediate access to advanced
technology and the finest clinicians in the world.
Beyond our technical capacities is an element of humane concern for all people, and a desire
to assure that everyone has access to the health care they need. In New Jersey, medical indigents
as well as Medicaid patients have the same access to doctors and hospitals as the insured patient.
Over $600 million yearly of hospital indigent patient services are funded by a surcharge on health
insurers, while an additional $300 to $500 million of physician services are provided voluntarily,
without compensation, by the doctors of New Jersey.
It has been difficult, and is becoming more difficult, for the state and federal governments
to properly fund Medicaid, and for providers to deliver care to the uninsured. The current
program is institutionally focused and is very expensive, lacking continuity of care, preventive
medicine, and the dignity of delivery that our citizens deserve. It is possible that the current
$2 billion operating budget can be redirected to enhance both the quality and quantity of services
so that hospitals are not used as physicians’ offices.
Such a revision would place the Medicaid patient into the mainstream of health care. This
would maximize efficiency and permit hospitals to concentrate on those patients whose severity
of illness warrants hospital-based care.
Given the background of our environment, it is necessary to note that our current delivery
systems, both ambulatory and inpatient, provide consistently high quality and reasonably priced
services. A recent study by New Jersey Citizens’ Action revealed that the average United States
citizen spends $2,251 yearly for health care, while New Jersey residents spend $1,643. New Jersey,
therefore, is significantly below the national average, and only marginally ahead of the Canadian
average of $1,515 per person. Economic factors, the complexity of society, and concern for the
treatment environment differ dramatically between Canada and New Jersey, so the relative
parity of these cost figures is remarkable.
While our system has done well, it is under stress. Care for the uninsured and the Medicaid
patient must be funded in a more stable and equitable fashion. New Jersey citizens must be
assured of access to care in an environment acceptable to patients, physicians, and hospitals.
Physicians and hospitals must be allowed to function in an environment that permits professional
freedom while requiring public accountability.
HEALTH ACCESS NEW JERSEY
The major thrust of the Medical Society of New Jersey and the physicians it represents
is to search for ways to expand access to care for those persons in New Jersey who have no
■
785
VOL. 87— NUMBER 10 OCTOBER 1990
9mmrn,mmm i.iijuh ii.uimh!
POSITION PAPER
Table. Health Cost Data— New Jersey.
$ 150 million
$ 400 million
$ 2 million
$ 2.5 million
$ 2.5 million
$ 250 million
$ 650 million
$ 300-500 million
Uncompensated Hospital Care
Uncompensated Physician Care
Under-reimbursed Physician Care in Medicaid
Hospital and Doctor Malpractice Premiums
Auto Surcharge— Doctors
Auto Surcharge— Medical Inter-Insurance Exchange of New Jersey
Auto Surcharge — Princeton
Medicare Undercompensation of Doctors
$ 1.757 billion
$ 1 billion
(Estimated Defensive Medicine Cost)
$ 2.757 billion
$ 5 million
Total
Malpractice Surcharge— State JUA
$ 2.762 billion
Conclusion: There are $2,762 billion being added to the cost of health care in New Jersey related to governmental
policies that force cost shifts to private patients, and the failure of government to address professional liability
reform.
insurance or who lack adequate health insurance coverage, while seeking ways to reduce the
spiraling cost of health care.
It is clear that some segments of our system in New Jersey need major restructuring. This
restructuring needs to be accomplished in a manner that does not jeopardize access to quality
care or strong aspects of our current system.
Health Access New Jersey presents a challenge to governmental forces in the state. The
challenge is whether this administration is willing to pay for access to care for all those who
cannot provide it for themselves. Certain priorities must be considered:
There is a need for statewide dialogue to address these changes and critical issues. The
problems facing the New Jersey health care system cannot be solved by any one group —
government or the private sector. A collaborative process should be pursued, with government
and medicine working together for the best interests of our citizens.
Certain conceptual elements must become governmental policy goals. These include:
1. Ensure that most patients have the ability to choose the physicians, hospitals, and
systems of health care that they want and with which they are comfortable.
2. Create incentives to make available new technology.
3. Sustain a medical education system that seeks to attract the best and brightest stu-
dents, leading them into a rigorous and comprehensive learning process that will assure
the public of well-trained physicians in the future.
4. Nurture professional ethics, prudent judgment, and professional freedom in the delivery
of health care to the citizens of New Jersey.
5. Take steps to reduce the reasons creating the need for physicians to practice defensive
medicine.
To accomplish Health Access New Jersey, several specific activities are needed.
Role of Government
A. Increase access to care by enacting major Medicaid reforms. It is distressing that Medi-
caid is so abysmal. New Jersey should assure that all persons of low and poverty income levels
are eligible for adequate benefits so that this group is not left without access to needed health
care. Perhaps a Medicaid eligibility standard of 185 percent of the federal poverty level could
be a goal that will allow for coverage of most uninsured. All basic medical benefits must be
786 MEW JERSEY MEDICINE
1. Revenues may have to be transferred between or among current programs.
2. New sources of revenue may have to be found.
3. Public support for legislation necessary to bring about concrete changes will have to
be developed.
HEALTH ACCESS PLAN— NEW JERSEY
POSITION PAPER
covered. There should be no rationing of care nor skimping of funds. Physicians and hospitals
should be paid fairly for services rendered to Medicaid patients, at least at the same rate the
federal government pays for Medicare patients.
B. Create a state-operated health insurance pool for small employers similar to the state-
operated insurance mechanism for temporary disability benefits. The thousands of small em-
ployers and their employees would comprise an underwriting pool of tens of thousands that could
be effectively and efficiently insured.
C. Increase access to care by creating state level risk pools that would make available
coverage for those who are unable to obtain affordable health care insurance. These pools would
ensure that no one in New Jersey would be denied health care insurance because of a particular
health condition. They also would guarantee continued health care coverage when persons are
changing jobs.
D. Reduce health care costs through professional liability reform. This would reduce the
practice of defensive medicine. It is estimated that defensive medicine adds approximately 15
to 25 percent to the total health bill. There are estimates that defensive medicine may approach
$20 to $30 billion yearly in the United States, and perhaps more than $1 billion per year in
New Jersey. Reform should be designed to lower frequency and severity of speculative litigation,
while preserving the rights of injured patients.
Areas for a legislative approach include: require a certificate of merit as a prerequisite to
file a liability case; adoption of basic medical expert witness criteria; limitation of $250,000 on
recovery of noneconomic damages; periodic payment of future awards for damages; and declaring
a definite statute of limitations.
E. Develop professional practice parameters to help assure that only high-quality ap-
propriate medical services are provided. This will impact favorably on quality and cost of medical
care. Such parameters would be professionally developed strategies for patient care, developed
to assist physicians in clinical decision making.
F. Urge more state, federal, and medical school support for medical education and research.
We must increase state grants/scholarships to ease the widespread anxiety among medical
students about their ability to finance their medical education. The accumulated debt of many
students is overwhelming, and this is due largely to the fact that many students come from
middle-to-low income families who cannot make substantial financial contributions to the
education of their children.
G. We can reduce health care costs by reducing the administrative cost of health care
delivery and excessive paperwork forced onto patients, their families, and their physicians. The
frustrations of physicians in dealing with differing managed care requirements of multiple
insurance companies and government programs result in increased office costs and interference
with the physician/patient relationship.
Role of the Medical Community
A. Encourage health promotion and disease prevention, including healthier lifestyles. We
must promote programs that will eliminate smoking, decrease alcoholism and drug abuse, reduce
cholesterol, encourage better adolescent health practices, and decrease the spread of AIDS.
B. Encourage physicians to practice with the highest ethical standards. We should en-
courage all physicians to treat their patients as individuals; to use the best possible judgment
in every case regarding quality of care; to inform patients (when possible) of the usual risks,
complications, and alternatives regarding health care, and the costs of such care; to treat patients
with courtesy, dignity, respect, compassion, and attention; and to overcome bias in the treatment
of AIDS patients.
C. Develop standard practice parameters for all specialties of medical practice.
SPECIAL PROBLEMS
A. Uncompensated Care.
1. Increase the Medicaid eligibility levels to 185 percent of the federal poverty level so
that more persons are covered under Medicaid.
2. Provide state-operated insurance pools so all employers can participate.
3. Eliminating the usual “pre-existing loss” requirement and the waiting period required
by insurance companies would allow persons to have continued health care coverage
when changing jobs.
VOL. 87— NUMBER 10 OCTOBER 1990
787
POSITION PAPER
B. Certificate of Need.
The Certificate of Need program (CON) should be re-evaluated. Our state has a hospital
rate-setting mechanism that makes the CON program in its present form obsolete. Nationally,
at least 12 other states have repealed their CON legislation as they developed rate-setting
mechanisms. If, however, the state wishes to continue the program, modifications should be
studied. Among the points to be considered are: removing the reouirement of a CON for
diagnostic technology; and in the alternative, raise the entry level fo. CONs from the current
base of $400,000 cost factor to $2 million.
There has been considerable speculation that the governor and the Commission believe that
the CON must be extended to physicians to create a level playing field. While MSNJ does
not agree with that goal, it understands but does not believe it can be practically or equitably
achieved. Hospitals are multimillion dollar corporate conglomerates. They employ hundreds of
people and retain batteries of lawyers, accountants, and financial advisers. The current CON
system is dominated by hospital interests. Most of the persons in the approval cycle either are
directly or indirectly (but very significantly) connected to hospitals.
Certificate of need extension to physician offices clearly interferes with the physicians’
ability to exercise their legally franchised right to practice what they in fact have been trained
to do. As an example, the radiologist is trained and licensed to practice radiologic services, that
may include all forms of imaging. Forcing such a physician to obtain a CON to practice his
specialty in a private office setting is an improper intrusion and restriction of the physician’s
right to practice what he has been licensed to perform.
Further, the restrictive CON process now in place, particularly as it applies to diagnostic
services, has fostered the proliferation of private imaging services because of demands for access
to such services and the limited access in hospital settings.
Therefore, in the context of a CON for physicians in New Jersey, the following concerns
must be addressed:
There must be careful consideration as to when a CON is required. Everything
that a doctor does in his office also is done by doctors in hospitals. The point of
attachment needs to be selected with such concern so that it does not destroy the
opportunity for the private practice of medicine, if we are to avoid a monolithic
system.
The decisional apparatus must be patently objective and cannot demonstrate
the slightest appearance of impropriety. The current CON apparatus does not meet
this test. Hospital interests are evident and controlling. Decisions will need to be
insulated from undue influence, and those making the decisions cannot have a
direct or indirect interest in the outcome. It is difficult to envision how the current
composition of either the SHCC or the HCAB can meet the test of objectivity
required. Either a new format or a reconstituted SHCC and/or HCAB must be used,
with the appointees being full-time governmental employees (other than those
whose duties involve operating hospitals).
Physicians must be granted fair, nondiscriminatory, and equal access to con-
trolled technology. If the state is to apply CONs to the physician community, then
the recipient of CONs must be required to permit all physicians within the defined
geographic region access to the equipment. If the equipment requires specialty
designation or skills, it would be appropriate to require that physicians applying
for “use” privileges demonstrate their qualifications.
Application of current reimbursement rules that apply to hospitals granted a
CON, that include extraordinary rate relief when the hospital faces bankruptcy
in the operation of its services, must be extended to physicians who are subject
to the CON process.
In summary, the CON process neither has contained costs nor produced maximum utiliza-
tion of available health dollars. The CON system has been used to direct sophisticated technology
to failing urban hospitals in an effort to stabilize their poor financial positions. This activity
neither is compatible nor consistent with natural market forces. It has not been successful and
is not likely to be successful.
Rather than focus on the CON as a planning method, the state should re-evaluate the
concept and consider using a strategic planning model in its place.
788
NEW JERSEY MEDICINE
POSITION PAPER
C. DRGs. This system of payment to hospitals has proved to be inadequate and expensive,
and should be eliminated. The federal government reportedly will be abandoning it in the next
several years. Other states have more efficient and effective methods to finance hospital care
than New Jersey. A study presented to the New Jersey State Department of Health several years
ago indicated that the “Share system was just as effective and less expensive to manage in
New Jersey.
A system is needed which is truly prospective and permits rapid decision making on the
rate-setting process. Hospitals should not be penalized for making rate review requests. However,
the system should truly reward those hospitals that operate efficiently and penalize those that
do not.
D. Medicaid. The Medicaid program in New Jersey has not provided quality care on a
routine basis to recipients. The provider fee schedule is woefully substandard, and the federal
Health Care Financing Administration has notified the state government that because of low
provider reimbursement and its adverse impact on participation, the program is dangerously
close to a declaration of noncompliance.
State administrators have not recognized the flawed approach of the substandard fee sched-
ule and have not corrected it. Instead, they have concentrated for over five years on a managed
care or HMO concept that has not been accepted by Medicaid patients or health care providers.
What the Medicaid administrators have not recognized is that managed care is not a broad
spectrum solution. It will only succeed when there are highly motivated patients, and highly
motivated physicians.
The best course for Medicaid is a multifaceted system. A viable fee-for-service program must
be offered and does have a place. Fee for service has never been given a chance, and it clearly
deserves an opportunity to succeed.
Fee for service with realistic utilization controls provides cost effective, high-quality services
and assures access.
Managed care is not a panacea. In those instances where it is used, it must be monitored
to assure that underutilization, lack of access, and loss of quality are not occurring.
E. Physician Self-Referral to Diagnostic Services. Physician self-referral to diagnostic ser-
vices in which they hold an economic interest is an important issue being studied on both the
state and federal levels.
Certainly if a service is considered essential to a physician’s specialty, it should be available
through the physician. Cardiologists, for example, must have immediate access to x-ray, EKGs,
and certain laboratory tests. Orthopaedists and physiatrists must have x-ray capability, and
frequently do and should provide physical therapy, on site, under direct supervision. These
instances are not all inclusive, but do demonstrate high-quality, cost-effective medicine.
Physician referrals to diagnostic centers in which they have an interest should be governed
by advance disclosures to the patient with an option for the patient to go elsewhere. Hospital
staff appointments are of significant economic interest to physicians. Physician referrals to the
hospitals where they hold privileges are also subject to potential abuse, and must be carefully
monitored.
F. Medicare Mandated Assignment. One of the major reasons for the rise in the cost of
care is that the group of patients paying for services at regular rates is decreasing in ratio to
the indigent, and those covered by Medicare and Medicaid. Senior citizens have pressed for
mandatory assignment. Many seniors have significant incomes and assets. It is unfair to the
nongovernment program patient to limit the liability of seniors who are well-off. A senior with
a $25,000 annual income is far better off than a family of four with an income of $30,000.
Mandated assignment is unnecessary in light of federal law which limits balance billings
to the federally approved MAAC level. That level has consistently declined, and will be further
reduced on January 1, 1991.
SUMMARY
We feel these proposals will strengthen the New Jersey health care system. They present
an enormous challenge for this administration and to all concerned. We welcome and encourage
your support, and anticipate a long-term close relationship between government and physicians,
hopefully working together to bring about the best possible health care to all the citizens of
New Jersey. ■
VOL. 87— NUMBER 10 OCTOBER 1990
789
Magnetic Resonance Imaging
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790
NEW JERSEY MEDICINE
Legal Implications of
Routine Screening
for Asymptomatic Silent Myocardial Ischemia
LEON G. SMITH, MD
RICHARD E. BRENNAN, ESQ
KATHLEEN H. DOOLEY, ESQ
A recent case in California raises legitimate concern about the risks of a
lawsuit arising out of a routine physical examination. This ruling has an
ominous portent for many physicians who either are not current or are not
comfortable with the available testing procedures for screening
asymptomatic patients for silent myocardial ischemia.
A case in California raises legitimate concern
about the risks of a lawsuit arising out of
a routine physical examination. A 40-year-
old white asymptomatic male underwent an annual
physical examination that essentially was un-
remarkable except his cholesterol was elevated at
250 mg/dL with a high-density lipoprotein level con-
sidered to be borderline low. His resting electrocar-
diogram (ECG) was interpreted as normal and his
blood pressure was 140/90; he smoked two packs of
Dr. Smith is chairman of the Department of Medicine,
Saint Michael's Medical Center, Newark, and Mr. Bren-
nan and Ms. Dooley are affiliated with Shanley & Fisher,
Morristown. This paper was submitted in May 1990 and
accepted in June 1990. Requests for reprints may be
addressed to Dr. Smith, Saint Michael’s Medical Center,
268 Martin Luther King, Jr. Blvd., Newark, NJ 07102.
cigarettes per day and had a positive family history
of acute myocardial infarction. The physician in-
structed the patient to lose weight, eat less red meat,
and exercise more. One month later, the patient died
suddenly of a myocardial infarction. An autopsy re-
vealed advanced triple-vessel coronary artery dis-
ease with a fresh thrombotic occlusion of the right
coronary artery.1
An arbitration panel in California awarded the
patient’s family a $500,000 malpractice judgment,
ruling that because of the presence of multiple risk
factors for coronary artery disease, even in the
absence of angina or prior myocardial infarction, an
exercise stress test should have been performed. In
short, the arbitration panel held that the physician
simply did not go far enough to rule out silent
myocardial ischemia (SMI).
VOL. 87— NUMBER 10 OCTOBER 1990
791
This decision has been criticized in the medical
field as a usurpation of community standards.2 In
terms of its legal implications, the ruling undoubted-
ly has an ominous portent for many physicians who
either are not current or are not comfortable with
the available testing procedures for screening
asymptomatic patients for SMI.
“Silent” ischemia was recognized more than a half
century ago. Recently, however, considerable atten-
tion has been given to this potentially lethal disease.
Defined as objective evidence of myocardial
ischemia in the absence of angina or equivalent
symptoms,3 SMI is a common occurrence in all
forms of coronary artery disease (CAD). Since 1981,
patients with SMI have been classified into three
clinical types: type 1 persons who are totally
asymptomatic, never having had any signs or symp-
toms of CAD; type 2 persons who are asymptomatic
cols,4 although it appears a screening test that is 10(
percent sensitive and specific has yet to be de
veloped. Given this element of uncertainty and the
fact many patients fall within the type I classi-
fication, physicians increasingly are recognizing the
necessity as well as the difficulty of screening foi
asymptomatic-risk patients. Nevertheless, where
improvements are recognized in diagnostic proce-
dures that readily are available, it is incumbent
upon the physician, as a precautionary measure for
the physician as well as the patient, to require the
patient undergo tests; anything less may be deemed
malpactice.
Generally, a physician is held to a reasonable
standard of care. The physician who fails to exercise
the degree of care, knowledge, and skill ordinarily
possessed and exercised in similar situations by the
average member of the profession in the field is guil-
SMI poses serious management problems for the physician at-
tempting to screen asymptomatic patients. Preventive measures
virtually are nonexistent and screening techniques yield less than
perfect results. In addition , the physician is confronted with under-
lying cost-effectiveness concerns associated with administering a
battery of tests that may prove unnecessary.
after a myocardial infarction; and type 3 persons
who demonstrate both symptomatic and asympto-
matic episodes.3 Sudden death has been associated
with type 1 SMI — per year in the United States,
approximately 50,000 of 250,000 sudden death vic-
tims have no history of heart disease, yet autopsies
throughout the country reveal advanced arterio-
sclerotic cardiovascular disease and scars in their
myocardium.4
SMI poses serious management problems for the
physician attempting to screen asymptomatic pa-
tients. Preventive measures virtually are nonexis-
tent3 and screening techniques yield less than perfect
results. In addition, the physician is confronted with
underlying cost-effectiveness concerns associated
with administering a battery of tests that, for many
patients, may prove unnecessary.
Although there are varying reports in the litera-
ture regarding the appropriate evaluation of the
asymptomatic patient with risk factors, it generally
is agreed that SMI can be discovered during exercise
stress testing or Holter monitoring, despite the low
predictive value and the high risk of false positive
results of such procedures. Some literature, however,
suggests that the diagnostic value of Holter monitor-
ing has been enhanced by technologic refinements
and the development of appropriate testing proto-
ty of professional negligence or malpractice if the
deviation of the standard of care results in the pa-
tient’s death.3 Moreover, the duty to use care ex-
tends to a physician, who in the exercise of his pro-
fession examines a person at the request of an em-
ployer, regardless of whether a physician-patient re-
lationship exists.6
The decision to screen a patient for SMI requires
the exercise of reasonable prudence on the part of
the physician. A review of relevant case law in-
dicates that in view of the availability of screening
techniques and their general acceptance as
diagnostic tools, reasonable prudence will require
the physician to have the high-risk cardiac patient
undergo more than just an ECG. Moreover, that
reasonable prudence may at times require the physi-
cian to order a series of seemingly unnecessary tests
as a precautionary measure is not a new concept in
the law. In fact, over 50 years ago a court went so
far as to state that with respect to reasonable
prudence “there are precautions so imperative that
even their universal disregard will not excuse their
omission.”7
An example of such imperative precautionary
measures can be seen in an opinion entitled Helling
versus Carey: A 32-year-old women sued two
ophthalmologists for failure to diagnose glaucoma by
792
NEW JERSEY MEDICINE
means of a pressure test. Medical experts for the
patient and the physician testified that the stan-
dards of ophthalmology under the same or similar
circumstances did not require routine pressure tests
for patients under 40 years of age because the occur-
rence of the disease in that age group was a rarity.
The court, however, held that even though they did
not violate the standard of care existing within their
profession, under the facts of this unique case, the
ophthalmologists were negligent in their failure to
give the pressure test to the patient under 40 years
of age. In a later case, Gates versus Jensen, the court
held that where a glaucoma pressure test proved
inconclusive in a high-risk patient, reasonable
prudence required the ophthalmologist to perform
alternative diagnostic tests.1 2 3 4 5 6 7 8 9
In the 1970s, courts began to rule that physicians’
failures to inform pregnant women of the availability
of the relatively new prenatal diagnostic procedure
known as amniocentesis constituted a deviation
from accepted medical standards.10 More recently,
a federal court found negligence where treating phy-
sicians failed to conduct tomograms to diagnose
osteomyelitis."
The physician’s failure to utilize generally ac-
cepted diagnostic aids will be deemed a violation of
the applicable standard of care. A medical mal-
practice treatise written over 20 years ago indicated
that failure to take an ECG did not constitute
negligence.12 In the early 1970s, however, the ECG
emerged as part of the usual diagnostic procedure.13
In determining whether a physician has breached
the duty of care owed to the cardiac patient, courts
will consider advances in the profession, as well as
all the medical resources and facilities available,
such as radionuclide imaging techniques, stress
testing, and ambulatory ECG monitoring. While
this may be perceived as heightening the requisite
standard of care, in a broader sense it sets a standard
no higher than that applied to other practitioners
under similar circumstances.14 Furthermore, be-
cause of the improved quality of medical training,
the modernization of communication and transpor-
tation, the proliferation of medical literature, the
scheduling of seminars and conferences on a variety
of medical subjects, the growing availability of mod-
ern clinical facilities, and the standardization of
medical schools through a national accrediting sys-
tem, the majority of courts long have discarded the
locality rule,15 opting instead for application of a
regional or national standard of care.
Moreover, a physician will not be held liable for
an honest error in diagnosis or in judgment, provided
the physician has brought the requisite degree of
care and skill to the patient.16 Given the complex-
ities of CAD, a physician may successfully defend
a malpractice action if the plaintiff is unable to show
that a correct diagnosis would have prevented a
myocardial infarction or that it would have in-
creased the chances of survival. It is, however, essen-
tial that a physician be able to articulate the reasons
for the course of action taken and that these reasons
be grounded in common sense and logic. If a physi-
cian is to err, it is best to do so on the side of
caution.12
It especially is important for physicians to realize
that upgrading of technological diagnostic tools will
invariably redefine the standard of care. As the com-
bination of procedures such as radionuclide imaging
techniques, stress testing, and ambulatory ECG
monitoring become regarded as acceptable possible
aids for diagnosis of silent myocardial ischemia, par-
ticularly in men over 40 with one or more coronary
risk factors, the result is an expansion of the phy-
sician’s duty within the applicable standard of care.
In terms of legal objectives and preventive measures
against malpractice, physicians can be guided by the
emerging clinical goals that seek to establish the
presence and severity of SMI and to guide its treat-
ment: namely, awareness of the possibility of silent
myocardial ischemia and the use of commonly avail-
able tests.17 ■
REFERENCES
1. Fuerst M: Silent ischemia: Lawsuit could mandate
screening. Med World News 28:19, 1988.
2. Assey ME: Screening for silent myocardial ischemia.
Am Fam Physician 38:143-146, 1988.
3. Cohn PF: Silent myocardial ischemia — classification
and management. Hosp Pract 25:45-50, 1990.
4. Cohn PF: Silent myocardial ischemia. Ann Intern
Med 109:312-317, 1988.
5. Walck versus Johns-Manville Products Corp., 56
N.J. 533, 267 A. 2d 508 (1970).
6. Beadling versus Sirotta, 41 N.J. 555, 197 A. 2d 857
(1964).
7. The T.J. Hooper, 60 F.2d 737, 740 (2d Cir. 1932).
8. 83 Wash. 2d 514, 519 P.2d 981 (1974).
9. 92 Wash. 2d 246, 595 P.2d 919 (1979).
10. Berman versus Allan, 80 N.J. 421, 404 A. 2d 8 (1979).
11. Sewell versus United States, 629 F. Supp. 448 (W.D.
La. 1986).
12. Sagall EL, Reed BC: The Heart and the Law.
Chapter 5, §7 (1968).
13. Harney DM, Medical Malpractice §9. 3(C) (1973);
Walck versus Johns-Manville Products Corp., 56 N.J. 533,
267 A. 2d 509 (1970).
14. Zaremski MJ, Goldstein LS, 2 Med. & Hosp. Neg.
§25:12 (Callaghan 1988).
15. Shilkret versus Annapolis Hospital, 276 Md. 187,
349 A. 2d 245 (1975).
16. Schueler versus Strelinger, 43 N.J. 330, 204 A. 2d 577
(1964).
17. Moskowitz RM, Chatterjee K, Parmley WN: Silent
myocardial ischemia: An update. Med Clin North Am
72:1033-1054, 1988.
VOL. 87— NUMBER 10 OCTOBER 1990
793
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794
NEW JERSEY MEDICINE
Carotid
Endarterectomy
Under Local Anesthesia
KENNETH S. FRIED, MD
STEVEN M. ELIAS, MD
ROBERT RAGGI, MD
Carotid endarterectomy has been used increasingly in the management of
cerebrovascular disease. However , morbidity and mortality statistics for this
procedure have caused criticism. The authors believe neurologic and medi-
cal complications can be reduced with the use of regional anesthesia for
carotid endarterectomy.
Carotid endarterectomy, the second most
common vascular operation performed in
the United States, is utilized in the preven-
tion of transient ischemic attacks and strokes orig-
inating from arteriosclerotic disease at the carotid
bifurcation. However, its efficacy recently has come
under scrutiny in the medical literature and by the
public. The procedure remains controversial for two
major reasons: indications for the operation continu-
From Englewood Hospital, where Drs. Fried and Elias are
affiliated with the Department of Surgery and Dr. Raggi
is affiliated with the Department of Anesthesiology. The
manuscript was submitted in February 1990 and ac-
cepted in May 1990. Requests for reprints may be
addressed to Dr. Fried, 180 North Dean Street,
Englewood, NJ 07631.
ously are being redefined, and the major complica-
tion of the surgery, permanent dysfunction of the
ipsilateral cerebral hemisphere, is exactly what the
procedure attempts to prevent. Because stroke is
such a devastating event, it is imperative that
vascular surgeons maintain a neurologic morbidity
considerably below that representative of the dis-
ease’s natural history. In addition, most of the pa-
tients undergoing carotid endarterectomy have sig-
nificant cardiac disease and are at risk for related
morbidity when subjected to this operation. We be-
lieve that with carotid endarterectomy performed
under regional anesthesia in the fully conscious pa-
tient, neurologic and associated medical complica-
tions can be reduced significantly. At New York
University, this approach has been utilized in over
VOL. 87— NUMBER 10 OCTOBER 1990
795
Figure. Carotid endarterectomy.
© Frank Cecala
90 percent of 1,500 carotid endarterectomies.1 Other
researchers have reported similar large experiences
with excellent results using local or regional
anesthesia.23
TECHNIQUE
Anesthesia consists of a superficial and deep
cervical block. A toy squeaker, held by the patient
in the contralateral hand, is used to monitor cerebral
circulation.4 A test occlusion of 60 seconds’ duration
determines the need for an indwelling shunt. The
internal carotid artery (ICA) is clamped first to
minimize the possibility of plaque dislodgement into
the ICA circulation. During this time, as well as
earlier when the vessels initially are exposed, the
patient is observed for changes in cerebral function
manifested by loss of consciousness, the appearance
of focal neurologic deficits, or the inability to con-
tinue to squeak the toy in the contralateral hand.
If the test occlusion is well tolerated, the physician
proceeds with the endarterectomy while the
anesthesiologist continues to reassess the patient’s
neurologic status.
METHODS
We present a series of patients from Englewood
Hospital, with successful carotid arterial reconstruc-
tion with regional anesthesia. Over a two-year
period, 20 carotid endarterectomies were performed
utilizing this technique. An increased interest in re-
gional anesthesia within the Department of
Anesthesia helped to employ this approach. In the
small group of patients, no neurologic morbidity, no
local problems secondary to the technique, and no
associated medical complications occurred. Two pa-
tients (10 percent) required subsequent placement
of intraluminal shunts without resort to induction of
general anesthesia.
Under general anesthesia, cerebral function must
be monitored directly by electroencephalogram
(EEG)3 or indirectly using another index of cerebral
perfusion such as ICA stump pressure.6 Approx-
imately 20 percent of patients undergoing surgery
will require shunting to preserve neurologic function,
slightly more in the presence of contralateral oc-
clusion.1,7 The different monitoring modalities at-
tempt to identify these patients without allowing
any deficits to occur because of imprecise calcu-
lations.
EEG generally is considered too sensitive to use
and is better for assessment of global rather than
regional ischemia, the major concern during carotid
endarterectomy.8 Inaccurate readings may occur
with changes in anesthetic depth or with changes in
PAC02. In addition, all inhalation agents cause
dose-dependent increase latency in waveform, thus
796
NEW JERSEY MEDICINE
obscuring real ischemic changes. In carotid end-
arterectomy opposite a contralateral occlusion, ap-
proximately 50 percent of patients develop an ab-
normal EEG mandating shunt placement.9 In a simi-
lar study in conscious patients, only 15 to 20 percent
of patients required shunt placement.10 Clearly,
many of the patients did not require a shunt and
could have avoided the possible morbidity as-
sociated with its use.
Carotid stump pressure measurements have failed
to provide reliable criteria for the need for shunt-
ing.11 Ostensibly, they reflect contralateral blood
flow to the ipsilateral hemisphere. However, pres-
sure studies are not always a valid index of cerebral
perfusion or flow. The previously accepted level of
50 mm/Hg has proved to be unreliable." In awake
patients undergoing the procedure, several patients
with higher pressures did not remain conscious when
these measurements were taken.
As a consequence, many vascular surgeons rec-
ommend routine shunting although 5 percent may
fail to function due to atherosclerosis or thrombosis
of the common carotid artery. Longer periods of
ischemia associated with higher dissection to facili-
tate placement may not be tolerated, and, worse
still, this fact will not be recognized perioperatively
under general anesthesia. Safe clamping time varies
depending on collateral circulation; it is believed
that irreversible neurologic defects may develop in
under two minutes. Embolism also may occur during
insertion. These potential problems argue against
routine shunting, a necessity if EEG or stump pres-
sures are not reliable.1 2 3 4 5 6
DISCUSSION
Neurologic morbidity in patients intact preoper-
atively ranges from 2 to 5 percent, though much
higher rates have been reported in other subgroups.
A report from Karmody and colleagues showed a
statistically significant difference in neurologic com-
plications between regional and general anesthesia,
0.6 percent versus 4 percent.12 Further, randomized
studies will be necessary. Regardless, complications
related to use of intraluminal shunts can be effec-
tively reduced in the awake patient by allowing most
operations to be completed safely without shunts.
Non-neurologic morbidity is significantly greater
under general anesthesia,7 2.8 percent versus 12.9
percent. Complications either are pulmonary or
cardiac; myocardial infarction and congestive heart
failure (CHF) are the most prevalent complications.
Regional anesthesia leads to a lower morbidity by
limiting blood pressure swings and the need for
vasoactive drugs.
Carotid endarterectomy with regional anesthesia
is well tolerated by the patient; it is safe and re-
liable. The major advantage of the procedure is that
it allows direct monitoring of cerebral function in the
conscious patient. Deficits can be identified and cor-
rected immediately.
CONCLUSION
Despite reports showing excellent results with
carotid endarterectomy performed in community
hospitals, fewer patients currently are being referred
for this procedure.13 Perhaps, with local or regional
anesthesia available as an option, patients with ap-
propriate indications more readily will be offered
surgery. We believe regional block is the technique
of preference in the high-risk patient and should be
strongly considered for all patients undergoing this
procedure. ■
REFERENCES
1. Imperato A, Riles T, Ramirez A: Cerebral protection
in carotid surgery. Arch Surg 117:1073-1078, 1982.
2. Hafner CD, Evans WE: Carotid endarterectomy with
local anesthesia: Results and advantages. J Vase Surg
7:232-239, 1988.
3. Slutzki S, Behar M, Negri M, et al.: Carotid end-
arterectomy under local anesthesia supplemented with
neuroleptic analgesia. Surg Gynecol Obstet 170:141-144,
1990.
4. Spielberger L, Turndorf H, Imperato A: Handheld
toy squeaker during carotid endarterectomy in the awake
patient. Arch Surg 114:103-104, 1979.
5. Baker JD, Gluecklich B, Watson CW, et al.: An
evaluation of EEG monitoring for carotid surgery. Surg
78:787-792, 1975.
6. Crawford ES, Debakey ME, Blaisdel FW, et al.:
Hemodynamic alterations in patients with cerebral ar-
terial insufficiency before and after operation. Surgery
48:76-81, 1960.
7. Peltzman AB, Webster MW, et al.: Carotid end-
arterectomy under regional anesthesia. Ann Surg
117:59-62, 1982.
8. Evans WE, Hayes JP, Waltke EA, et al.: Optimal
cerebral monitoring during carotid endarterectomy: Neu-
rologic response under regional anesthesia. J Vase Surg
2:775-777, 1985.
9. Phillips MR, Johnson WG, Scott M: Carotid en-
darterectomy in the presence of contralateral carotid oc-
clusion. Arch Surg 114:1232-1239, 1979.
10. Riles TS, Imperato AM, Kopelman J: Carotid
stenosis with contralateral internal carotid artery oc-
clusion. Long-term results in 54 patients. Surgery
87:363-368, 1980.
11. Hobson RW, Wright, CB, Siblett JW, et al.: Carotid
artery back pressure and endarterectomy under regional
anesthesia. Arch Surg 109:682-687, 1974.
12. Corson JD, Chang BB, Karmody AM: The influence
of anesthetic choice on carotid endarterectomy outcome.
Arch Surg 122:807-812, 1987.
13. Kirshner DL, O’Brien MS, Ricotta JJ: Risk factors
in a community experience with carotid endarterectomy.
J Vase Surg 10: 178-186, 1989.
VOL. 87— NUMBER 10 OCTOBER 1990
797
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798
NEW JERSEY MEDICINE
Maintaining an
Office Laboratory
KATHLEEN L. VOLDISH, CLA (ASCP)
The author discusses the need to have a complete, up-to-date procedure
manual available at all times; information on ways to investigate reference
laboratories is included.
LABORATORY PROCEDURE MANUAL
Question: We are interested in developing a
procedure manual for tests performed in an office
laboratory. What should be included in these
procedures?
Answer: A written procedure manual, for use by
all personnel performing laboratory procedures, is
one way to enhance performance in the office labora-
tory. These test procedures should include patient
preparation, specific instructions, such as fasting
and special diet, specimen collection, including an-
ticoagulants or other preservatives, and any other
special instructions or processing, such as special
timing considerations. In addition to the detailed
procedure (step-by-step directions), instructions
should be given on how to prepare all reagents, stan-
dards, and controls. This should include any safety
information associated with the reagents, controls,
or instrumentation. Instrumentation maintenance
and frequency of calibration should be defined.
The procedure manual should describe how re-
sults are derived, any necessary calculations (a
precise example is beneficial), units for reporting the
results, and the range of linearity. Any actions re-
quired when results exceed the tolerance limits
should be defined. Reference ranges along with criti-
Ms. Voldish is a registered technologist and laboratory
manager. Questions for this column were answered by
POL Committee members Deborah Hassler, MT (ASCP)
and Diana Headly, MT (ASCP). Questions can be ad-
dressed to Ms. Voldish, 1150 Concord Drive, Haddon-
field, NJ 08033.
cal values and limitations of the method, e.g. inter-
fering substances, should be noted. Describe accept-
able alternative procedures.
Manufacturer product inserts may be used to sup-
plement the written procedure but must not take the
place of a precise manual. If used as a supplement,
inserts must be checked frequently for changes by
the manufacturer.
Changes or corrections to individual pages should
be dated and noted on a review page. Periodically,
all personnel performing testing should review each
procedure, which should be documented on comple-
tion by initialing and dating a review page.
The National Committee for Clinical Laboratory
Standards published Guidelines for Clinical Labora-
tory Procedure Manuals, Volume 4, Number 2, de-
tailing each of the areas to be included in a
procedure.
While writing procedures can be time consuming,
it is good laboratory practice to have individualized
procedures for each of the tests performed.
REFERENCE LABORATORIES
Question: Our office has always used a particular
reference laboratory, but lately I have been dis-
satisified with its service and reliability. How can I
investigate reference laboratories when shopping for
a new one?
Answer: Choosing a new reference laboratory to
meet all your needs is a formidable task. Because
there may be a variety of requirements that you wish
the reference laboratory to meet, it may be helpful
VOL. 87— NUMBER 10 OCTOBER 1990
799
for you to make a list and compare each laboratory.
1. Test Menu. Does the laboratory perform the
type of tests that you will refer to them? Do they
specialize in a particular type of assay, such as toxi-
cology or endocrinology? What laboratory do they
use when referring tests?
2. Specimen Handling. The laboratory should
provide a manual describing the specimen require-
ments for each test, specimen volume needed, and
any special handling (frozen, whole blood, or fasting)
that may be required. Other features that may be
noted in this manual are CPT code, test fee, assay
time, reference range, department, interferences, or
test methodology. Specimen containers, mailers,
and request forms should be provided. Are the re-
quest forms preprinted with your facility name, ad-
dress, and telephone number? How and when will
the specimens be picked up? Does the laboratory use
a commercial courier or do they have their own? Will
the transporter have the ability to maintain proper
temperatures for various tests enroute to the labora-
tory? Is the specimen traceable from the time it
leaves your laboratory until it is received at the
reference laboratory? The laboratory should have
specific guidelines in specimen rejection.
3. Turnaround Time. The laboratory should state
the normal turnaround time for routine tests and
special assays. Find out what their guidelines are for
STAT testing.
4. Test Reports. An example of various test re-
ports should be available for you to view. Several
factors should be included on those reports including
patient identification, physician name, specimen
date and time (if a timed specimen), specimen re-
sult, reference range (age- and sex-adjusted, if ap-
propriate), and some Hag of a result outside the
reference range. Make sure that the reports are easy
to read and understand. Determine which test will
contain an interpretive report such as protein elec-
trophoresis. How are the test reports returned to
your laboratory? Reference laboratories use a variety
of means, including mail, courier, remote printing,
facsimile, or telephone. Does the reference labora-
tory have a list of tests where results always are
telephoned? Can your laboratory request a tele-
phoned report? Is there a list available that contains
“panic” values to merit immediate notification of
the physician?
5. Consultation. Many reference laboratories are
now offering various types of consultation services.
If you contact the laboratory for information, how
difficult is it to speak to someone in a technical area?
Is it possible for the physician to discuss a case with
a pathologist? Do the pathologists contact the phy-
sician concerning abnormal tissue consultation or
other consultations to help in the managment of the
patients? Is there someone available to speak with
24 hours a day, or only from 8 A.M. to 5 P.M., Monday
through Friday? Is there a specific contact you can
establish a relationship with or is there simply an
anonymous voice at the other end of the line?
6. Licenses or Credentials. Learn what licenses
are necessary to operate a laboratory in your state.
Do the laboratories you are investigating meet these
requirements? Laboratories operating across the
state lines must be licensed according to the Clinical
Laboratory Improvement Act (CLIA) of 1974. Is the
laboratory Medicare approved or accredited by such
agencies as CAP or JCAHO? Each of these agencies
has its own set of standards the laboratory must
meet to uphold its accredited standing.
7. Fees. When fees among laboratories are com-
pared, be sure to consider the type and volume of
tests you will be referring. A high fee on a test that
may never be requested should be inconsequential
to your decision. Inquire about additional discounts
that may be available based on a variety of methods.
Determine if there are any “hidden” fees for items
such as general consultations, a “simple advise,”
supplies, requisitions, computer usage, shipping, or
postage costs. Realize that the lowest fee does not
always justify the selection of a certain laboratory.
A laboratory may have slightly higher fees, but the
value gained in additional services may far outweigh
the difference.
8. Extra Service. Many laboratories will offer ad-
ditional services as part of their package or offer a
fee-for-service basis. They may help in instrument
or kit selection, test cost analysis, determining ap-
propriate laboratory fees, correct CPT coding for
laboratory procedures, routine newsletters, training
in certain procedures, or continuing education
geared to the office staff. Perhaps the physician is
planning a remodeling or building project and would
like advice about the laboratory design. These ser-
vices should only be limited by your imagination. A
reference laboratory can be the first place you turn
when seeking help with anything concerning labora-
tory medicine.
9. Reputation. Finally, contact current clients of
the laboratory to ask about its track record. Does the
laboratory make promises with no follow through?
Determine the laboratory service record. Is the lab-
oratory prompt in solving problems? Does the lab-
oratory have a reputation for quality and integrity?
These areas are just a sampling of items to con-
sider when investigating reference laboratory ser-
vices. If you are looking at more than two or three
laboratories, the information could become quite
confusing. A helpful means of organizing the infor-
mation is to develop a checklist of the important
factors pertinent to your situation. Check off those
that are offered by each laboratory researched. This
will help in justifying your final decision. ■
800
NEW JERSEY MEDICINE
Carcinoma of the
Male Breast
JEFFERY W. SEITZINGER, MD
Carcinoma of the male breast remains an unusual entity. Because of this,
large series of patients are infrequent and a standard of care has not been
established. In this study, 31 male patients with mammary carcinoma were
treated over a 29-year interval. The course of these individuals was examined
and comparisons were made with the existing literature.
Carcinoma of the male breast was recognized
in 1307 by John of Aderne. In the early
1500s, similar reports were made by Fran-
ciscus Arcaeus, Ambroise Pare, and Fabricius
Hildanus. Male breast carcinoma is a rare lesion,
accounting for approximately .2 percent of all
cancers and less than 1.5 percent of all cancers in
men.2 There are an estimated 900 cases per year. The
female: male ratio has been reported at between
100:1 and 160:1. 4,5
Dr. Seitzinger is chief resident, Department of Surgery,
Saint Barnabas Medical Center. This paper was sub-
mitted in April 1990 and accepted in May 1990. Requests
for reprints may be addressed to Dr. Seitzinger, Saint
Barnabas Medical Center, Old Short Hills Road, Liv-
ingston, NJ 07039.
This report analyzes the experience of mammary
cancer in men at a large, suburban hospital in
New Jersey and compares the findings with the
literature.
MATERIALS AND METHODS
Appropriate data were retrieved from the hospital
records of all male patients with breast cancer
treated at Saint Barnabas Medical Center, Liv-
ingston, during the period January 1970 through
March 1989. Additional information was collected
from the Saint Barnabas Medical Center Tumor
Registry and from attending physicians during fol-
lowup intervals extending to 14 years. Patient inter-
views were conducted when possible.
VOL. 87— NUMBER 10 OCTOBER 1990
803
Figure 1 . As with females, a lump in the male breast is the most
frequent presenting complaint.
Using data available from the records, all patients
were staged according to the TNM classification.
PATIENT INFORMATION
During the investigative period, a total of 31 males
with mammary carcinoma were evaluated at Saint
Barnabas Medical Center. The patient population
included 9 patients who received primary treatment
at another institution but were referred for adjuvant
therapy. All patients were followed at regular inter-
vals by their physicians. Annual evaluation of the
patient’s condition was obtained and recorded by
the Tumor Registry through questionnaires.
RESULTS
General. Thirty-one males with mammary
carcinoma presented from 1970 through March 1989.
The men were 46 to 87 years of age at the time of
diagnosis; the average age was 62. Twenty-nine of
the 31 men (94 percent) were white; there was 1
black man and 1 Hispanic man.
Presenting Complaint. Twenty-five men (81 per-
cent) sought medical assistance because of a mass
in the breast. Two additional lumps were discovered
incidentally by a physician. Of the remaining 4 pa-
tients, 2 patients presented with nipple inversion
and two patients presented with bleeding from the
nipple (Figure 1).
Delay. The length of delay in seeking medical
attention was ascertained in 21 of the 31 men (Figure
2). The shortest delay was two weeks; the longest
delay was 20 years. Of the 21 men, 11 men (52 per-
cent) delayed six months or less. Five men (24 per-
cent) delayed for one year. All of the ten men who
had delayed longer than six months in seeking medi-
cal attention reported they finally obtained help be-
cause of a change in the character of their mass. In
5 men, the change consisted of an increase in the size
of the lump. Two men sought medical attention be-
cause the mass had become painful. Three men re-
quired attention because of ulceration of the skin.
Site. The laterality of the affliction was nearly
equal. Sixteen men (52 percent) had right-sided
lesions while 14 men (45 percent) had lesions on the
left. There was 1 patient (3 percent) with bilateral
carcinoma.
Risk Factors. Risk factors for the development of
breast cancer also were evaluated. Gynecomastia
was reported in 3 patients (10 percent). A heavy
smoking history (greater than 20-pack years) was
found in 35 percent. Eleven patients (35 percent)
had a family history of cancer including cases of
colonic, prostatic, ovarian, uterine, and gastric
carcinoma, and sarcoma. There were 4 patients (13
percent) with a family history of breast cancer and
2 patients had multiple occurrences within the fam-
ily. In addition, there were 4 patients (13 percent)
with a second primary carcinoma, including cutane-
ous carcinoma, oral cavity carcinoma, and hyper-
nephroma.
Therapy. The therapy of these patients was
varied and included combinations of surgery, radio-
therapy, chemotherapy, and hormal therapy. Mod-
ified radical mastectomy was the most frequently
performed surgical procedure, accounting for 65 per-
cent of the cases. Seven patients (23 percent) under-
804
NEW JERSEY MEDICINE
went radical mastectomy. Two patients underwent
biopsy alone because of advanced disease. One pa-
tient each underwent segmental mastectomy with
axillary dissection and one patient had lumpectomy
alone. Fifty-eight percent of the patients received
additional therapy in various combinations of
chemotherapy, radiation therapy, and hormonal
therapy.
Histopathology. Histologically, 90 percent of the
tumors were of the infiltrating ductal type. Of these,
two tumors (6 percent) were subclassified as inflam-
matory carcinoma and one tumor (3 percent) was
classified as comedocarcinoma. The remaining 10
percent included two cases of intraductal carcinoma
and one case of infiltrating lobular carcinoma.
Estrogen receptor studies were available for 12
patients. All patients (100 percent) demonstrated
estrogen receptor positivity. Progesterone receptor
studies were available in 10 patients; of these, only
three studies (30 percent) were positive.
Stage and Survival. All stages of disease were
encountered in the patient population (Figure 3).
Five patients (16 percent) presented as stage I and
all remain alive today; the longest survival in this
group is greater than 14 years. Fifteen patients (48
percent) presented as stage II and 67 percent of these
Number of Patients
<6 6-12 24-48 >120
Delay (months)
Figure 2. Fifty-two percent of the men delayed six months or less in seeking medical attention.
Incidental
Percentage of Patients
Stage
1 I Alive IHHIlill Expired
Figure 3. Nearly two-thirds of the men presented as either stage I or stage II.
VOL. 87— NUMBER 10 OCTOBER 1990
805
Table 1. Survival by stage.
Stage Five Year Ten Year
Combined 52% 31%
I 100% 100%
II 56% 17%
III 75% 50%
IV 17% 0%
patients remain alive with the longest survival being
11 years and 8 months; of the deceased stage II
patients, the average survival was 45.6 months and
the longest survivor in that group remained alive for
78 months. Five patients (16 percent) comprised the
stage III group. Two stage III patients remain alive
with survival lengths of 61 and 82 months; of those
in stage III who died, the average survival was 44.3
months. Six patients (19 percent) presented as stage
IV and 1 patient has remained alive for 57 months;
the average survival for the expired stage IV men
was 33.4 months.
Five- and ten-year survival rates for the men were
calculated as 52 percent and 31 percent, respective-
ly, for all stages combined. The five- and ten-year
survival rates by individual stage are found in Table
1.
Cause of Death. The cause of death also was
examined. Of the 13 men (42 percent) who suc-
cumbed, 11 men (85 percent) died of breast cancer.
In addition, one patient died of congestive heart
failure and one man died of complications following
a cerebrovascular accident.
Tumor Status. The tumor status of the survivors
was evaluated. In stage I, four of the men have no
evidence of disease. The status of the fifth is un-
known since he has refused medical followup. For
the survivors in stage II, seven men (70 percent) have
no evidence of disease and three men (30 percent)
have distant metastases. Two men (20 percent) have
had local recurrences in addition to distant spread;
of the two survivors in stage III, one patient is free
of disease while the other has suffered both distant
metastases and local recurrence. The single stage IV
survivor has distant metastases. A patient summary
for stages I through stage IV is presented in Tables
2 through 6.
DISCUSSION
Assuming there are 900 new cases of male breast
cancer per year,3 the experience of this hospital rep-
resents approximately .1 percent of the nation’s ex-
perience. However, taken collectively, a series of 31
patients is substantial when compared with other
series in the literature.
Male breast cancer has been described in patients
from 5 to 91 years of age. Carcinoma of the male
breast is rare in those less than 40 years of age. The
average age of presentation (62 years) is 10 years i
older for males than for females.4 The average age
in this series corresponds exactly.
The finding that 94 percent of patients are white
is comparable with other figures.1-2 It has been re-
ported6 that male breast cancer is less frequent in i
blacks; however, in a West African series by Ajayi,
a frequency rate of 2.4 percent seems to contradict
this statement.7 The rate of 3.2 percent in this series
is consistent with Ajayi’s finding. Breast carcinoma
in Hispanic males is exceedingly rare and has not
been adequately reported.
The presenting symptoms are similar to those
found in the female. A lump in the breast is the most
frequent complaint. Most cancers lie immediately
beneath or within a few centimeters of the areola.8
Crichlow’s finding that 33 percent are associated
Table 2. Summary of stage I patients.
Delay Additional
Age
(Months)
Surgery
Therapy
63
12
Modified
radical
mastectomy
Negative
58
4
Modified
radical
mastectomy
Negative
55
24
Modified
radical
mastectomy
Radiotherapy,
chemotherapy
59
Unknown
Lumpectomy
Negative
55
Unknown
Radical
mastectomy
Radiotherapy
Histology
Tumor
Status
Survival
(Months)
Intraductal
No evidence
of disease
26
Infiltrating
ductal
No evidence
of disease
5
Infiltrating
lobular
No evidence
of disease
7
Intraductal
Unknown
129
Infiltrating
ductal
No evidence
of disease
169
806
NEW JERSEY MEDICINE
with nipple retraction and ulceration is double the
16 percent rate found in our patients.9 The 6 percent
who presented with discharge from the nipple cor-
responds with reports by Scheike.10
Many authors have noted that breast carcinoma
in men usually is more advanced.45811 Bavafa re-
ported 52 percent of patients as either stage III or
stage IV.4 Similarly, Langlands11 and Scheike8 re-
ported 65 percent and 54 percent, respectively, as
either stage III or stage IV. This has been ascribed
to the statement that men delay in seeking advice
twice as long as females.4
Table 3. Summary of living stage II patients.
However, only 35 percent of the patients in this
series were stages III and IV and 52 percent delayed
six months or less. These disparities with previous
reports are explained by such possible factors as a
more educated and health conscious society, as well
as a better awareness of the disease itself.
The reported overwhelming preference for occur-
rence on the left side12 has not been substantiated
in this group where less than half of the patients had
left-sided lesions. The single case of bilateral
carcinoma reported here is exceedingly rare.
Regarding risk factors for the development of
Age
Delay
(Months)
Surgery
Additional
Therapy
Histology
Tumor
Status
Survival
(Months)
56
.5
Radical
mastectomy
Negative
Infiltrating
ductal
No evidence
of disease
106
52
Unknown
Modified radical
mastectomy
Radiotherapy
Infiltrating
ductal
Distant
metastases
68
73
1
Radical
mastectomy
Radiotherapy
Infiltrating
ductal
No evidence
of disease
78
52
2
Modified radical
mastectomy
Chemotherapy
Infiltrating
ductal
No evidence
of disease
27
65
12
Modified radical
mastectomy
Negative
Infiltrating
ductal
Distant metastases
local recurrence
42
57
12
Radical
mastectomy
Negative
Infiltrating
ductal
No evidence
of disease
140
87
6
Modified radical
mastectomy
Negative
Infiltrating
ductal
No evidence
of disease
16
75
Incidental
Modified radical
mastectomy
Negative
Infiltrating
ductal
No evidence
of disease
21
46
Unknown
Modified radical
mastectomy
Radiotherapy,
chemotherapy,
hormonal therapy
Comedo-
carcinoma
Distant metastases
local recurrence
39
63
240
Modified radical
mastectomy
Negative
Infiltrating
ductal
No evidence
of disease
12
Table 4. Summary of expired stage II patients.
Age
Delay
(Months)
Surgery
Additional
Therapy
Histology
Cause of
death
Tumor
status
Survival
(Months)
70
12
Modified radical
mastectomy
Radiotherapy,
chemotherapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases,
local recurrence
38
72
3
Modified radical
mastectomy
Hormonal
therapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
55
49
Incidental
Radical
mastectomy
Negative
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
53
59
Unknown
Modified radical
mastectomy
Chemotherapy,
hormonal therapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
74
81
12
Modified radical
mastectomy
Negative
Infiltrating
ductal
Congestive
heart failure
No evidence
of disease
8
VOL. 87— NUMBER 10 OCTOBER 1990
807
breast cancer in the male, several points deserve
comment. A history of heavy smoking and a family
history of cancer was found in a significant propor-
tion of the patient population. While these factors
may not be related specifically to the development
of mammary cancer, they are indicators of the pa-
tient’s general health and genetic background. The
finding that two patients had multiple familial oc-
currences of breast cancer is important and should
be considered a significant risk factor.
An interesting and often described feature of male
breast cancer is its association with Klinefelter’s
syndrome. Klinefelter’s syndrome (genotype XXY)
is a condition associated with diminished
testosterone levels and an increased incidence of
gynecomastia. Generally, it is believed that
Klinefelter’s syndrome is the single factor that most
predisposes to male breast cancer with the risk being
20 times higher than in normal men (and aboul
one fifth the frequency in normal women).13 An ex
planation is not clear; however, the relatively high
levels of plasma estrogen seem to be an important
factor. Despite these reports, no cases ol
Klinefelter’s syndrome were identified in this series.
Gynecomastia itself is suggested as a predisposing
factor, but reports are conflicting and the frequency
of such an association is variable. The 10 percent
incidence in this series is far below the 27 percent
reported by Scheike and Visfeldt.14
Another purported feature of male breast cancer
patients not supported by this study is the increased
incidence of second primaries. Forty-one percent
have been described to have large bowel or rectal
primaries.11 No such patients were identified. Of the
four (13 percent) with second primaries, the develop-
ment of cutaneous carcinoma in two patients may
Table 5. Summary of stage III patients.
Age
Delay
(Months)
Surgery
Additional
Therapy
Histology
Cause of
death
Tumor
status
Survival
(Months)
56
36
Modified radical
mastectomy
Radiotherapy
Infiltrating
ductal
Not
applicable
Distant
metastases,
local recurrence
61
55
2
Modified radical
mastectomy
Negative
Infiltrating
ductal
Not
applicable
No evidence
of disease
82
58
.5
Radical
mastectomy
Radiotherapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
17
51
2
Radical
mastectomy
Radiotherapy,
chemotherapy,
hormonal therapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
114
77
2
Modified radical
mastectomy
Negative
Infiltrating
ductal
Cerebro-
vascular
accident
No evidence
of disease
2
Table 6.
Summary of stage IV patients.
Age
Delay
(Months)
Surgery
Additional
Therapy
Histology
Cause of
death
Tumor
status
Survival
(Months)
55
48
Modified radical
mastectomy
Radiotherapy,
chemotherapy
Inflammatory
Not
applicable
Distant
metastases
57
62
Unknown
Modified radical
mastectomy
Radiotherapy,
chemotherapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases,
local recurrence
30
62
Unknown
Modified radical
mastectomy
Radiotherapy,
chemotherapy,
hormonal therapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases,
local recurrence
78
82
1
Biopsy
Radiotherapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
7
58
Unknown
Biopsy
Radiotherapy,
chemotherapy
Infiltrating
ductal
Mammary
carcinoma
Distant
metastases
8
63
120
Segmental
mastectomy
axillary dissection
Radiotherapy,
chemotherapy,
hormonal therapy
Inflammatory
Mammary
carcinoma
Distant
metastases
44
808
NEW JERSEY MEDICINE
be explained by the advanced age of these patients.
The patient with oral cavity carcinoma predictably
was a heavy smoker. The only remaining patient had
an additional hypernephroma.
Histologically, male and female breast pathologies
are similar. Approximately 90 percent are infiltrat-
ing ductal, with intraductal being the second most
common form at 7 percent.1 2 3 4 5 6 7 8 9 10 11 Cases of medullary,
comedocarcinoma, and lobular carcinoma are rare.
The finding of inflammatory carcinoma in two pa-
tients has been poorly documented previously but
should be considered unusual.
An unusually high proportion of male breast
carcinoma has been found to be estrogen receptor
positive. The figure of 80 percent is approximately
double that for females.15 The 100 percent positivity
rate in this series probably is skewed by the small
number of patients who received this test.
It generally is believed that male breast cancer has
a poor prognosis in relation to females with the same
affliction. Crude five-year survival rates vary from
19 to 83 percent.16,17 However, figures from the Na-
tional Cancer Institute’s Surveillance, Epidemiology
and End Results (SEER) Program reveal com-
parable five- and ten-year survival rates of 60 per-
cent and 37 percent for males and 65 percent and
47 percent for females, respectively.18 The observed
five- and ten-year survival rates of 52 percent and
31 percent in this series correlated well with those
statistics when all stages are considered collectively.
However, the five- and ten-year survival rates for
stage II patients are more dismal than would be
expected for similarly staged females.19 By the same
token, stage III patients in this series fared better
than would be expected, at least in the five-year
1. Vercoutere AL, O’Connell TX: Carcinoma of the
nale breast, an update. Arch Surg 119:1301-1304, 1985.
2. Hodson GR, et al.: Male breast carcinoma. Am Surg
51:47-49, 1985.
3. Silverberg E, Lubera JA: Cancer statistics, 1989.
Ca — Cancer J Clin 39: 3-20, 1989.
4. Bavafa S, et ah: An updated experience at a Vet-
eran’s Administration Hospital and review of the litera-
:ure. J Surg Oncol 24:41-45, 1983.
5. Panettiere FJ: Cancer in the male breast. Cancer
14:1324-1327, 1974.
6. Moss NH: Cancer of the male breast. Ann NY Acad
Sci 114:937-950, 1964.
7. Ajayi DOS, et ah: Carcinoma of the male breast in
Vest Africans and a review of the world literature. Cancer
>0:1664-1667, 1982.
8. Scheike O: Male breast cancer. Six factors influenc-
ng prognosis. Br J Cancer 30:261-271, 1974.
9. Crichlow RW: Carcinoma of the male breast. Surg
jynecol Obstet 134:1011-1019, 1972.
10. Scheike O: Male breast cancer: Clinical mani-
estations in 257 cases in Denmark. Br J Cancer
>8:552-561, 1973.
11. Langlands AO, et ah: Carcinoma of the male breast:
survival category. Possible explanations for these
disparities include the fact that 60 percent of stage
II patients in this series were diagnosed less than five
years ago and, therefore, were not included in the
survival data. If their prognosis is truly similar to
their female counterparts, we would expect most of
these patients to have a long survival. In addition,
the survival rate is greatly affected by the small
number of patients in each category.
The outlook for these patients, in general, is not
favorable. Of those patients who died, the majority
(85 percent) have died from breast disease. In ad-
dition, nearly one third of the living males have
metastases at present and likely will succumb to
their disease as well. An exception to this poor prog-
nosis would appear to be those diagnosed as stage
I and treated aggressively.
SUMMARY
A series of 31 male patients with mammary
carcinoma has been presented. The rarity of this
entity makes large series over a short interval unlike-
ly and precludes all but a few from becoming special-
ists in dealing with this disease. This may explain
the disparity in individual reports found in the
literature. Great strides have been made in alerting
the population of the existence of male breast
cancer. It remains, however, the duty of the physi-
cian to examine his patients with this diagnosis in
mind. Risk factors such as a family history of breast
cancer and a history of Klinefelter’s syndrome
should alert one’s suspicion. Other features such as
nipple discharge and a lump, all lend support to the
diagnosis. An aggressive approach to therapy then
is warranted. ■
Report of a series of 88 cases. Clin Radiol 27:21-25, 1976.
12. Sanchez AG, et al.: Lobular carcinoma of the breast
in a patient with Klinefelter’s syndrome. Cancer
57:1181-1183, 1986.
13. Scheike O, et al.: Male breast cancer. Breast
carcinoma in association with Klinefelter’s syndrome.
Acta Pathol Microbial Scand 81:352-358, 1973.
14. Scheike O, Visfeldt J: Male breast cancer.
Gynecomastia in patients with breast cancer. Acta Pathol
Microbiol Scand 81:359-365, 1973.
15. Van Geel AN, et al.: A retrospective study of male
breast cancer in Holland. Br J Surg 72:724-727, 1985.
16. Wainwright JM: Carcinoma of the male breast:
Clinical and pathological study. Arch Surg 14:836-859,
1972.
17. Classen JN, et al.: Cancer in the male breast. Arch
Surg 100:66-67, 1970.
18. Myers MH, Gloeckler Ries LA: Cancer patient
survival rates: SEER Program results for ten years of
followup. Ca — Cancer J Clin 39:21-32, 1989.
19. Seidman H, et al.: Survival experience in the breast
cancer detection demonstration project (BCDDP). Ca —
Cancer J Clin 37:258-290, 1987.
/OL. 87— NUMBER 10 OCTOBER 1990
809
Established therapy
for today’s patients
For respiratory tract infections due to
susceptible strains of indicated organisms
“Recent research
has delineated
early, more subtle
changes in lung and
immune functions. These
alterations directly
predispose smokers to
respiratory tract infection.”
Am Fam Phys 1987;36:133-140
Brief Summary.
Consult dm package literature for prescribing information.
Indication: Lower respiratory infections, including
pneumonia, caused by Streptococcus pneumoniae,
Haemo0ius influenzae, and Streptococcus pyogenes
(group A p-hemolytic streptococci).
Contraindication: Known allergy to cephalosporins.
Warnings: CECLOR SHOULD BE ADMINISTERED
CAUTIOUSLY TO PENICILLIN-SENSITIVE PATIENTS.
PENICILLINS AND CEPHALOSPORINS SHOW PARTIAL
CROSS-ALLERGENICITY. POSSIBLE REACTIONS
INCLUDE ANAPHYLAXIS.
Administer cautiously to allergic patients.
Pseudomembranous colitis has been reported with
virtually all broad-spectrum antibiotics. It must be con-
sidered in differential diagnosis of antibiotic-associated
diarrhea. Colon flora is altered by broad-spectrum
antibiotic treatment, possibly resulting in antibiotic-
associated colitis.
Precautions:
• Discontinue Ceclor in the event ol allergic reactions to it.
• Prolonged use may result in overgrowth of non-
susceptible organisms.
• Positive direct Coombs’ tests have been reported
during treatment with cephalosporins.
• Ceclor should be administered with caution In the
presence of markedly impaired renal function. Although
dosage adjustments in moderate to severe renal
impairment are usually not required, careful clinical
observation and laboratory studies should be made.
• Broad-spectrum antibiotics should be prescribed with
caution in individuals with a history of gastrointestinal
disease, particularly colitis.
• Safety and effectiveness have not been determined in
pregnancy, lactation, and infants less than one month
old. Ceclor penetrates mother's milk. Exercise caution
in prescribing for these patients.
Adverse Reactions: (percentage of patients)
Therapy-related adverse reactions are uncommon.
Those reported include:
• Hypersensitivity reactions have been reported hi about
1.5% of patients and include morbilliform eruptions
(1 in 100). Pruritus, urticaria, and positive Coombs’
tests each occur in less than 1 in 200 patients. Cases
of serum-sickness-iike reactions have been reported
with the use of Ceclor. These are characterized by
findings of erythema multiforme, rashes, and other skin
manifestations accompanied by aiihritis/artbralgia, with
or without fever, and differ from classic serum sickness
in that there is infrequently associated lymphadenopathy
and proteinuria, no circulating immune complexes, and
no evidence to date of sequelae of the reaction. White
further investigation is ongoing, serum-slclutess-like
reactions appear to be due to hypersensitivity and more
often occur during or following a second (or subsequent)
course of therapy with Ceclor. Such reactions have been
reported more frequently in children than in adults with
an overall occurrence ranging from 1 in 200 (0.5%) in
one focused trial to 2 in 8,346 (0.024%) in overall
clinical trials (with an incidence in children in clinical
trials of 0.055%) to 1 in 38,000 (0.003%) in spon
taneous event reports. Signs and symptoms usually
occur a few days after Initiation of therapy and subside
within a few days after cessation of therapy; occasion-
ally these reactions have resulted in hospitalization,
usually of short duration (median hospitalization = two
to three days, based on postmarketing surveillance
studies). In those requiring hospitalization, the symp-
toms have ranged from mild to severe at the time of
admission with more of the severe reactions occurring
in children. Antihistamines and glucocorticoids appear
to enhance resolution of the signs and symptoms. No
serious sequelae have been reported.
• Stevens-Uohnson syndrome, toxic epidermal necrolysis,
and anaphylaxis have been repotted rarely. Anaphylaxis
may be more common In patients with a history of
penicillin allergy.
• Gastrointestinal (mostly diarrhea): 2.5%
■ Symptoms of pseudomembranous colitis may appear
either during or after antibiotic treatment.
• As with some penicillins and some other cephalo-
sporins. transient hepatitis and cholestatic jaundice
have been reported rarely.
• Rarely, reversible hyperactivity, nervousness, Insomnia,
confusion, hypertonia, dizziness, and somnolence have
been repotted.
• Other: eosinophilta, 2%; genital pruritus or vaginitis,
less than 1% and, rarely, thrombocytopenia and reversibte
interstitial nephritis.
Atmormallties in laboratory results of uncertain etiology,
• Slight elevations in hepatic enzymes,
• Transient lymphocytosis, leukopenia, and, rarely,
hemolytic anemia and reversible neutropenia.
• Rare reports of increased prothrombin time with or
without clinical bleeding in patients receiving Ceclor
and Coumadin concomitantly.
• Abnormal urinalysis; elevations in BUN or serum
creatinine.
• Positive direct Coombs' test.
• False-positive tests for urinary glucose with Benedict's
or Fehling's solution anti Clinltest* tablets but not with
Tes-Tape®’ (glucose enzymatic test strip, Lilly),
PA 8791 AMP (021490 LR1J
Additional information available to the profession
on request from Ell Lilly and Company, Indianapolis,
Indiana 46285.
Eli Lilly Industries, Inc
Carolina, Puerto Rico 00630
A Subsidiary of Eli Lilly and Company
Indianapolis, Indiana 46285
CR-0528-B-049333 © 1990, EU UUY ANO COMPANY
S&ty
810
NEW JERSEY MEDICINE
CASE REPORT
Squamous Cell
Cancer of the Larynx
in an Intravenous Drug User with AIDS
J.G. BARONE, MD
D. HUTCHINSON, MD
A.L. CUPPARI, MD
J.E. BARONE, MD
We present the case of a 29-year-old intravenous drug user with AIDS and
squamous cell cancer of the larynx. Profound immunosuppression was evi-
dent by an 0KT4.0KT8 ratio of 0. 1. Simultaneous treatment of the laryngeal
cancer by laser vaporization and treatment of immunosuppression with
zidovudine resulted in no tumor recurrence after one year.
Secondary cancers, including Kaposi’s sar-
coma and lymphoma, occur with increased
frequency in human immunocyte virus
(HlV)-infected patients.1'3 The following report is the
first case of squamous cell carcinoma (SCC) of the
larynx occurring in an intravenous drug user with
From the Department of Surgery, St. Francis Medical
Center, Trenton, where Drs. J.G. Barone and Cuppari are
residents in surgery, Dr. Hutchinson is chief of
otolaryngology, and Dr. J.E. Barone is chief of surgery.
The manuscript was submitted in April 1990 and ac-
cepted in June 1990. Requests for reprints may be ad-
dressed to Dr. J.G. Barone, 464 Northam Drive, North
Brunswick, NJ 08902.
acquired immunodeficiency syndrome (AIDS). We
discuss the management of squamous cell cancer
with respect to the profound immunosuppression
caused by HIV.
CASE REPORT
A 29-year-old male intravenous drug user was ad-
mitted to St. Francis Medical Center, Trenton, be-
cause of hoarseness of his voice. He denied cigarette
and alcohol use, and homosexual activity. Mild
supraclavicular adenopathy was present on physical
examination. White blood cell count was 2.2 x
10 9/L (3.2 - 9.8 x 109/L) with a total lymphocyte
count of 0.2 x 109/L (1.2 - 3.4 x 10VL). The
VOL. 87— NUMBER 10 OCTOBER 1990
811
OKT4:OKT8 ratio was 0.1. Antibody titers for HIV
were positive by enzyme-linked immunosorbent
assay (ELISA) and by Western blot. Microscopic
direct laryngoscopy demonstrated thickened
erythematous vocal cords. The abnormal tissue was
biopsied and then vaporized with a carbon dioxide
laser until healthy vocalis muscle was seen. The
biopsy specimen revealed primary laryngeal SCC in
situ. Oral zidovudine was started postoperatively
because of profound immunosuppression. The pa-
tient was discharged and maintained on zidovudine
with an improvement in the OKT4:OKT8 ratio to
0.2 after six weeks. Followup laryngoscopic exami-
nations have been negative for tumor at one year.
HIV infection progresses from the acute infection
to AIDS, the final stage of HIV infection. AIDS is
characterized by fever, weight loss, malaise, and the
development of opportunistic infections. A high in-
cidence of secondary cancers also develops during
the final stage of HIV infection, including Kaposi’s
sarcoma and lymphomas.1 The relationship between
HIV infection and squamous cell cancer is not firmly
established, but there is an increased incidence of
tumors of the oral cavity among homosexuals with
AIDS.2 3 Squamous cell cancers of the skin and
epiglottis also have been reported to occur in HIV-
infected patients.3,4
Our patient developed carcinoma of the larynx
and was profoundly immunocompromised as in-
dicated by a 0.1 OKT4:OKT8 ratio. All of the estab-
lished risk factors for laryngeal cancer were absent,
including age over 50 years, chronic irritation, and
tobacco and alcohol abuse. This suggests that HIV
or the profound immunosuppression it causes may
have played a role in the development of cancer in
our patient.
Physicians should try to obtain HIV antibody
titers if a patient at risk for this infection develops
an unusual cancer. Testing with ELISA detects anti-
body to viral particles and is highly sensitive, but
can produce false positive results.5 Western blot is
more specific since it uses electrophoresis to separate
viral antigens.5 It should be performed when the
ELISA is positive. If HIV infection is confirmed,
strong consideration should be given to treating both
the cancer and the immunosuppression caused by
HIV infection with zidovudine (200 mg orally every
four hours). In our patient, tumor vaporization and
treatment of immunosuppression resulted in no
tumor recurrence at one year. ■
REFERENCES
1. Centers for Disease Control: AIDS weekly surveil-
lance report. August 29, 1988, p. 1-5.
2. Lozada F, Silverman S Jr, Conant M: A new out-
break of oral tumors, malignancies, and infectious diseases
strikes young male homosexuals. Can Dent Assoc J
10:39-42, 1982.
3. Alhahimi MM, Krasnow SH, Johnston-Early A:
Squamous cell carcinoma of the epiglottis in a homosexual
man at risk for AIDS. JAMA 253:2366, 1985.
4. Overly WL, Jakubek DJ: Multiple squamous cell
carcinomas and human immunodeficiency virus infection.
Ann Intern Med 106:334, 1987.
5. Scutchfield FD, Benenson AS: AIDS update. Post-
grad Med 85:289-304, 1989.
812
NEW JERSEY MEDICINE
Parathyroid
Adenoma
with Conflicting Parathyroid Hormone Levels
MICHAEL H. GOLDMAN, MD
ARATI SURESH, MD
For discrepant diagnoses in a patient with hypercalcemia, the authors utilized
three different parathyroid hormone assays. The new two-site im-
munoradiometric assay (IRMA) proved to he the most accurate and is rec-
ommended in the differential diagnosis of hypercalcemia.
Problems interpreting parathyroid hormone
(PTH) assays in the differential diagnosis of
hypercalcemia are well known.12 We report
i patient having a parathyroid adenoma with con-
licting PTH determinations using different im-
nunochemical assays: carboxy (C)-terminal; amino
N)-terminal; and two-site (IRMA).
CASE REPORT
A 42-year-old female was evaluated for an
levated calcium level discovered on a routine
Dr. Goldman is attending physician, Department of Medi-
cine, and Dr. Suresh is a resident in internal medicine,
Englewood Hospital. The paper was submitted in April
1990 and accepted for publication in June 1990. Re-
quests for reprints may be addressed to Dr. Goldman,
Englewood Hospital, Englewood, NJ 07631.
chemistry screen (Table). Two years earlier, her
calcium level was normal. After discontinuing 500
mg of calcium supplement, a repeat calcium also
was elevated. She had no significant past medical
history and the family history revealed no calcium
disorders. Physical examination was completely un-
remarkable.
A PTH (C-terminal) level of 0.5 ng/mL (normal,
0.1-1. 8 ng/mL) was consistent with nonparathyroid
hypercalcemia. An N-terminal PTH (done mis-
takenly by the laboratory instead of an ordered
IRMA PTH) also was consistent with tumor of non-
parathyroid hypercalcemia. Routine chest x-ray,
mammogram, and angiotensin-converting enzyme
were normal. Mild primary hypothyroidism (TSH
6.2 [normal 0. 3-5.0 /*U/mL], with normal T4 and T3
resin), was successfully treated (TSH 1.5, on Sep-
/OL. 87— NUMBER 10 OCTOBER 1990
815
tember 9, 1989). Total 24-hour urinary calcium ex-
cretion was 250 mg/24 hours (normal, 50-275 mg/24
hours). Serum protein electrophoresis, tuberculosis
skin test, and standard chemistries including phos-
phate, chloride, albumin, and alkaline phosphatase
were normal. Also, 1-25 vitamin D was elevated at
48.4 pg/mL (normal, 16.4-42 pg/mL). An intact,
IRMA PTH was 84 pg/mL (normal, 10-65 pg/mL)
with a calcium of 11.3 (normal, 8.8-10.4) This was
consistent with primary hyperparathyroidism
(PHP). One month later, an N-terminal PTH (again
mistakenly done by the laboratory) was 16 pg/mL
(normal, 8-24 pg/mL) suggestive of “non-
parathyroid” replacement. An intact IRMA PTH
one month later, was 74 pg/mL, indicating PHP.
After thorough discussion with the patient,
emphasizing the fact that statistically she most like-
ly had PHP and that she had no evidence of any
secondary causes for hypercalcemia, the patient
agreed to have surgery. Our patient refused partici-
pation in a “natural history” study group of hyper-
calcemia.
A left lower pole parathyroid adenoma was re-
moved. A thyroid biopsy showed chronic
lymphocytic thyroiditis. Two months later, calcium
was normal at 8.9 mg/dL.
DISCUSSION
PTH determination is the diagnostic test of choice
in the differential diagnosis of hypercalcemia. It
most commonly is used to differentiate primary hy-
perparathyroidism (PHP) from other causes of hy-
percalcemia. The latter disorders include diverse en-
tities such as the use of pharmacologic agents
(thiazides and vitamins A and D), granulomatous
diseases (sarcoid and tuberculosis), malignant dis-
orders (with or without skeletal metastases), or other
endocrine pathology (Addison’s disease or thyrotox-
icosis). Unfortunately, PTH assays do not always
clearly segregate these conditions with the expected
elevated PTH levels in PHP and low PTH levels in
the secondary causes. Comparison of available as-
says, in 1979 and 1987, revealed this difficulty.1,2
Immunoheterogenicity of PTH in the circulation
and different antibody specificities account for the
conflict and overlap in the clinical utility of PTH
assays.
PTH is a single-chain polypeptide of 84 amino
acids.1’ The intact molecule is cleaved in the circula-
tion leaving N- and C-terminal fragments. The
biological activity of the hormone is localized within
the N-terminal position of the molecule (PTH 1-34);
antisera, directed towards the N-terminal portion,
will measure intact (1-84) hormone as well as N-
terminal fragments, i.e. 1-34. C-terminal antisera
will measure intact hormone and C-terminal frag-
ments, i.e. 53-84. Specific midregion assays measure
intact hormone and midsegment fragments.
Table.
Chemistry
screen.
Date
Calcium
Normal
PTH
(mg/dL)
(mg/dL)
10/87
10.4
8.5-10.8
4/89
11.4
8.5-10.6
7/89
11
8.5-10.6
0.5 mg/dL
7/89
10.7
8.8-10.4
20 pg/mL
9/89
10.8
8.8-10.4
9/89
11.2
8.8-10.4
84 pg/mL
10/89
11.3
8.8-10.4
16 pg/mL
11/89
11.1
8.8-10.4
74 pg/mL
12/89
8.9
8.7-10.7
Assay Type (Lab)
Comments
C-terminal
(Roche)
Nonparathyroid
Hypercalcemia
N-terminal
(Nichols)
Hypercalcemia
of malignancy
Intact IRMA
(Nichols)
Primary
hyperparathyroid
N-terminal
(Nichols)
Hypercalcemia of
malignancy
Intact IRMA
(Nichols)
Primary
hyperparathyroid
Postoperative
816
NEW JERSEY MEDICINE
Clinically, assays directed towards the C-terminal
and middle regions of PTH, have been shown to be
the most sensitive for the detection and evaluation
of hyperparathyroidism. N-terminal assays are more
helpful in certain situations such as the followup of
patients with chronic renal failure.1 2 3 4 This is due to
the short half-life of intact PTH (about six minutes)
while C-terminal PTH is longer (about one hour),
with the latter especially accumulating with pro-
gressive renal failure.
Recently, a two-site IRMA5 has been developed to
measure intact PTH without interference from frag-
ments. It is found that this new assay improves the
discriminatory ability of PTH in assessing calcium
disorders of patients with hyperparathyroidism from
hypercalcemia of malignancy.6 However, even with
this assay, 3 to 5 percent of patients with hyper-
parathyroidism have values at the upper range of
normal and 20 to 30 percent of patients with hyper-
calcemia of malignancy have low, but detectable
concentrations of intact PTH.
Another reason for variation in PTH levels is due
to a circadian rhythm of PTH; levels taken between
0200 and 0600 hours may be found to be physiologi-
cally elevated. A late morning or afternoon sampling
of PTH level is recommended.7 Because of the varia-
bility of the PTH assays, their high cost, and lengthy
analysis time, a number of ancillary tests have been
utilized to differentiate PHP from hypercalcemia of
malignancy. In one study, 18 different tests were
compared." Included were albumin, chloride, venous
Ph, phosphatase, phosphorus, chloride phosphate
ratio, and hematocrit. Individually, none of these
tests had better than 81 percent classification ac-
curacy. In general, findings related to malignancy
included a mild metabolic alkalosis, low albumin,
low red blood cell mass, and high alkaline phos-
phatase. Laboratory data, related to the action of
parathyroid hormone, included a low phosphate and
high chloride/phosphorous ratio. The authors con-
cluded that the commonly available auxiliary tests
do not help in the differential diagnosis of hyper-
calcemia and merely added to increased cost.
It has been suggested that 1-25 vitamin D is of
help in the differential diagnosis of hypercalcemia.
Stewart found high-normal, and elevated levels in
PHP, while low or low-normal levels were observed
in cancer-associated hypercalcemia.9 PTH stimu-
lates hydroxylation of 25 vitamin D to 1-25 vitamin
D; raised levels are consistent with PHP. Our pa-
tient has an increased level; however, this laboratory
test has been an inconsistent finding.
Another condition to be considered in this dif-
ferential diagnosis is familial benign hypercalcemia
(FBH).10 FBH is an autosomal dominant disorder of
calcium and magnesium metabolism characterized
by lifelong, symptomless, nonprogressive hyper-
calcemia with usually normal serum immunoreac-
tive parathyroid hormone concentrations and para-
thyroid glands that usually are grossly and his-
tologically normal. It is characterized by hypocal-
ciuric hypercalcemia and a low calcium to creatinine
excretion ratio. Our patient did not have these his-
torical or family findings. A calcium to creatinine
excretion ratio was not done.
Hypothyroidism also can cause reversible
hypocalciuric hypercalcemia with raised PTH and
Vitamin D." Our patient had mild hypothyroidism
but was successfully treated without resolution of
her hypercalcemia.
CONCLUSION
We report a case of PHP with conflicting C-ter-
minal, N-terminal, and IRMA assays. The IRMA
PTH assay was found to be the most reliable test
and currently is considered the best PTH assay,
differentiating hypercalcemia of PHP from other
causes. ■
REFERENCES
1. Raisz LG, Yanjnik CH, Bookman RS, Bower BF:
Comparison of commercially available parathyroid
lormone immunoassays in the differential diagnosis of
lyperparathyroidism or malignancy. Ann Intern Med
11:739-741, 1979.
2. Lufkin, EG, Kao PC, Hunter H: Parathyroid
lormone radioimmunoassays in the differential diagnosis
>f hypercalcemia due to primary hyperparathyroidism or
nalignancy. Ann Intern Med 106:559-560, 1987.
3. Keutman HT, Sauer MM, Hendy GN, et al.: Com-
pete amino acid sequence of human parathyroid
lormone. Biochemistry 17:5723-5729, 1978.
4. Frietag J, Martin KJ, Husha KA, et al.: Impaired
jarathyroid hormone metabolism in patients with chronic
enal failure. N Engl J Med 298:29-32, 1978.
5. Nussbaum, Zahradnik, Lavigne: Highly sensitive
wo-site immunoradiometric assay of parathyroid and its
•linical utility in evaluating patients with hypercalcemia.
Clin Chem 33:1364-1367, 1982.
6. Logue FC, Beastall GH, Fraser WD: Intact para-
thyroid assays. Br Med J 300:210-214, 1990.
7. Logue FC, Fraser WD, O’Reilly D.J, Beastall GH:
The circadian rhythm of intact parathyroid hormone
(1-84) and nephrogenous cyclic adenosine monophosphate
in normal men. J Endocrinol 121.-R1-3, 1989.
8. Boyd JC, Ladenson JH: Value of laboratory tests in
the differential diagnosis of hypercalcemia. Am J Med
71:863, 1984.
9. Stewart AF, Horst R, Deftos LJ, et al.: Biochemical
evaluation of patients with cancer-associated hyper-
calcemia. N Engl J Med 303:1377-1383, 1980.
10. Law WM, Hunter H: Familial benign hyper-
calcemia. Ann Intern Med 102:511-519, 1985.
11. Zaloga GP, Eil C, O’Brian JT: Reversible
hypocalciuric hypercalcemia associated with hypothy-
roidism. Am J Med 71:101-104, 1984.
OL. 87— NUMBER 10 OCTOBER 1990
817
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818
NEW JERSEY MEDICINE
Medical Services for the
Developmental^
Disabled
TED KASTNER, MD
JOAN LUCKHARDT, PhD
Access to medical care for people with developmental disabilities is a grow-
ing problem. The authors review the components of a health care delivery
system to help meet the special medical needs of this population.
Agrowing number of people with mental re-
tardation and other developmental dis-
abilities no longer live in institutions; they
live independent lives in New Jersey communities.
However, the inability of clients to receive adequate
health care in communities is an obstacle to their
receiving the benefits of community residence.
There are many complex reasons for this problem:
flaws in the health care system including limitations
Dr. Kastner is medical director, Developmental Dis-
abilities Center, Morristown Memorial Hospital and Dr.
Luckhardt is affiliated with UMDNJ-School of Os-
teopathic Medicine. This paper was submitted in Decem-
ber 1989, and accepted in May 1990. Requests for re-
prints may be addressed to Dr. Luckhardt, 385 Georges
Road, Dayton, NJ 08810.
of those responsible for direct care of the de-
velopmentally disabled; patients’ medical and be-
havioral problems; and physicians’ limitations.
Shortcomings in the health care delivery system can
be overcome only if physicians join with representa-
tives of state agencies and advocacy organizations to
create and implement a comprehensive plan for the
delivery of community-based health care services
serving this residential population.
A SHIFT TO RESIDENTIAL LIVING
Using a functional rather than a categorical defi-
nition of disability, over 20,000 New Jersey citizens
are eligible for state services. A person with a de-
velopmental disability is a person whose disability
appeared before age 22 and is unable to be indepen-
VOL. 87— NUMBER 10 OCTOBER 1990
819
dent in two or more activities of daily living. The
term encompasses people with mental retardation,
cerebral palsy, or other limiting conditions.
Currently, more than 5,000 of New Jersey’s dis-
abled citizens, most of them mentally retarded, live
in institutions or developmental centers operated by
the New Jersey State Division of Developmental
Disabilities. Many will leave for community resi-
dences as the aged facilities, some over 100 years old,
are closed. There are over 1,400 persons on waiting
lists for community placement and an additional
2,000 people, cared for by their families, also await
community placement.
A growing number of disabled individuals will
reach adulthood without having lived in an institu-
tion. Many live longer and develop skills enabling
them to hold competitive jobs in the community and
to live with minimum support. For this population,
health care is seen as a component of a residential
service package that includes residential care, oc-
cupational training, family services, and behavioral
treatments.
BARRIERS TO CARE
System barriers. Fragmentation of health care
Table 1 . Barriers to health care for
persons with developmental disabilities.
System Barriers
1 . Fragmented health care delivery system.
2. Lack of planning.
3. Excessive federal (HCFA) and state
regulation.
4. Low Medicaid reimbursement.
5. Long office visits with excessive paperwork.
Consumer Barriers
1. Frequent inability to communicate symptoms.
2. Lack of medical history.
3. More complex medical/behavioral problems.
4. Confusion around guardianship and informed
consent.
Provider Barriers
1 . Negative attitudes towards working with
people with developmental disabilities.
2. Architectural barriers.
3. Gaps in transportation.
4. Uneven geographic physician distribution.
5. Lack of medical school/residency training
combined with lack of clinical experience.
Direct Care Providers Barrier
1 . Inadequate training of direct care staff.
2. Excessive paperwork.
3. Crisis-oriented care.
services hinders care. When residential care first was
planned, social planners assumed appropriate medi-
cal care would be available in the community from
local physicians. In contrast, the state provided
medical services in institutions. However, physi-
cians and nurses employed in state institutions, ex-
cept in rare emergencies, do not provide medical
services to community residents.
Health care coordination is a major need for
people with developmental disabilities, yet health
care services for people with developmental dis-
abilities rarely are integrated with other services.1314
Coordination is necessary because many of the direct
care staff lack the skills needed to implement phy-
sician recommendations, observe client symptoms,
and relate information at followup.
Another problem, perhaps more easily solved, is
the excessive paperwork tied to documentation re-
quirements of the state or the residential care
provider. Each may require documentation beyond
that usually kept for billing or office medical charts.
(The form may emphasize incident reporting rather
than health maintenance or preventive care.)
Of all the major barriers, lack of money to buy
physician services is the most cited obstacle. Persons
with developmental disabilities do not readily access
care in a fee-for-service system. Certainly, low Medi-
caid reimbursements for services are significant dis-
incentives for health care providers (Table 1).
Medicaid reimbursement gives a set fee for each
visit, ignoring the length of a visit. Because patients
with developmental disabilities often require longer
office visits than other patients, the already low fee
becomes even lower. For these reasons, among
others, many doctors do not accept Medicaid pa-
tients, particularly new Medicaid patients.
In a telephone survey conducted by the New Jer-
sey State Department of Health, 80 physicians in a
rural county were interviewed in regard to Medicaid.
Of the 80, only 17 physicians said they accepted
Medicaid at all. Eight physicians said they would
accept new Medicaid patients but only in an emer-
gency situation. Only 2 physicians stated they would
accept new patients for routine care.
In another study, the New Jersey Association for
Retarded Citizens contacted four county Medicaid
offices to obtain health care for a specific client.
Only two physicians said they would accept new
Medicaid patients. In a shore community, a phy-
sician group wrote to the New Jersey State Depart-
ment of Health stating obstetricians no longer would
treat indigent or poor patients.
The difficulties faced by persons with de-
velopmental disabilities in New Jersey are similar to
those seen nationally. Approximately 76 percent of
clients with mental retardation who receive state
services are Medicaid eligible; in New Jersey, the
820
NEW JERSEY MEDICINE
figures are similar. Adults with mental retardation
who live in the community in Massachusetts aver-
aged little more than two physician contacts per
year. This low rate of utilization was attributed to
a low level of physician reimbursement ($22 per pri-
mary care visit), fragmentation of care, and lack of
coordinated treatment. New Jersey pays $12 per
visit.
Barriers presented by the patient. Persons with
developmental disabilities represent a unique
clinical challenge to the practitioner. Patients fre-
quently lack a medical history and can lack an abili-
ty to communicate symptoms. Minihan reports
physicians in Maine rank a lack of medical history
as the greatest barrier to medical care for people
with disabilities. 11,12 Moreover, their medical prob-
lems often are more complex than those of the gen-
eral population. The difficulties in treating people
with severe behavior problems are challenging. Last-
ly, issues of informed consent and guardianship
often are overlooked.
Physician barriers. Some physicians harbor
negative attitudes toward working with people with
developmental disabilities. In addition, lack of
specific training and experience in the care of per-
sons with developmental disabilities has a negative
impact on the quality of care. Garrard has stated
there is no evidence that access “to the community
health system [can] be readily achieved by this
group, that professionals [are to] be prepared to re-
Table 2. Basic issues in community-
based health care.
1 . Multiple options for the delivery of health care
must be used.
2. Each person should have a “medical home”
for stable primary care.
3. The concept of a health care network is
essential.
4. The network will require the presence of
resource centers for specialty care.
5. A health care clearinghouse should be
established.
6. A comprehensive record of personal health
status and standards for delivery of care are
needed.
7. Fees for service must be fair and set at the
prevailing market level.
8. Training is critical for workers at all levels.
9. Health services research and evaluation are
needed.
10. Coordination and watchdog components are
required.
‘Adapted from the Symposium on Community Health
Care Services for Adults with Mental Retardation, a
publication outgrowth of the Sterling D. Garrard Mem-
orial Symposium on Community Health Care Services
for Adults with Mental Retardation.
spond appropriately, or that services delivered meet
the requirements of the population.”6
Uneven distribution of physicians or lack of a re-
ferral network for this population also can decrease
the availability of medical care, particularly
subspecialty care. Minihan assessed the need for
physician services for institutionalized persons prior
to their transfer to community residential settings
and then followed their subsequent treatment by
community-based physicians. A reliance on existing
community physician services led to inadequate
medical care for a number of individuals.
Only a few persons were able to have their health
care needs met by the primary care physician alone.
Subspecialty services such as orthopedics, behav-
ioral medicine, neurology, and psychiatry generally
were not available in the community from physi-
cians with the experience and training necessary to
serve this group.
In a 1987 New Jersey survey, the southern region
of the Division of Developmental Disabilities found
only 77 percent of their clients had access to a per-
sonal physician. Only 1 percent of the clients had
seen a psychiatrist during 1987, although 18.5 per-
cent of the clients were taking psychotropic medi-
cations. (The southern region then served about
2,350 clients.)
DELIVERY SYSTEMS
In an effort to remedy these shortcomings, re-
searchers and advocacy organizations studied al-
ternative models of delivery of health care services.
No single design for the delivery of health care ap-
pears uniquely desirable or appropriate. The varied
conditions of rural, suburban, and urban living af-
fect the pursuit of medical care. Depending on the
circumstances, physicians in private practice, health
maintenance organizations (HMOs), community
health clinics, hospital-based clinics, home health
services, or even developmental center-based outpa-
tient care programs may all be appropriate.
After eight years of operation, one prepaid, man-
aged care plan operated at Morristown Memorial
Hospital seems to be effective. The core of the pro-
gram is health care coordination by nurses, who link
the patient to primary physician care and
subspecialty care, ensure adequate followup, and
complete the necessary paperwork.
New Jersey Medicaid recipients often have used
costly and episodic emergency room and hospital-
based outpatient programs for primary care. To help
provide preventative care, continuity of care, and
reduce costs, the New Jersey State Department of
Human Services initiated the Garden State Health
Plan, a Medicaid HMO, in which physicians are
paid a monthly fee to provide care for enrolled pa-
tients. Physicians receive a set amount, regardless
VOL. 87— NUMBER 10 OCTOBER 1990
821
of the frequency of patient visits. The program may
not best serve people with developmental dis-
abilities, eligible by virtue of their disability, who
may need more frequent visits to a physician to
maintain adequate health. As designed, it may bet-
ter serve the needs of the poor, who qualify for Aid
for Dependent Children. To the credit of the New
Jersey State Department of Human Services, it is
studying the undesirable effects of the program.
Medical issues. Cross-sectional studies measur-
ing the quality of health care services received by
persons with developmental disabilities in New Jer-
sey reveal that physicians need to be attentive to
possible deficiencies in preventive care, primary
care, and specialty services. For example, the staff
of Morristown Memorial Hospital Disabilities Clinic
surveyed the immunization status of 36 infants
identified as being at risk for developmental delay
and found that only 22 were appropriately im-
munized against pertussis. On a statewide basis, as
many as 900 children in early intervention programs
may be inadequately protected against pertussis.
While thyroid disease is a common problem in
patients with Down’s syndrome, this disorder often
is overlooked. In a survey of 178 patients with
Down’s syndrome living in 16 New Jersey counties,
20.3 percent of patients were found to have previous-
ly unrecognized hypothyroidism or low thyroid re-
serve. Additionally, 1.5 percent of patients with
Down’s syndrome were noted to have hyper-
thyroidism.
While the assessment of thyroid function is well
within the means of the general practitioner, access
to echocardiography probably reflects access to
medical subspecialists. In a survey of 157 people
with Down’s syndrome living in 15 New Jersey coun-
ties, 73 patients were noted to have either valvular
or congenital heart disease. However, in 86 percent
of these cases, cardiac findings previously had been
unrecognized. The failure to provide antimicrobial
prophylaxis to those patients with valvular lesions
who receive dental care can be a significant problem.
RECOMMENDATIONS AND CONCLUSIONS
Until public policy changes, physicians can lead
by personal example. Health care providers can ex-
press a greater willingness to serve this population —
even if the issues of funding and integration of health
care services remain unsolved. In addition, health
care providers can develop an awareness of the
special health care needs of this group and raise the
level of expertise available in the community.
The Medical Society of New Jersey and other pro-
fessional health care provider associations can shape
the New Jersey health care system to better serve
people with developmental disabilities. A policy
panel described ten basic issues as central to the
establishment of a successful health service system
for people with mental retardation who live in the
community (Table 2).
Increasing fees for service at prevailing market
rates are necessary. Developing multiple options for
the delivery of health care will require research and
funding and joint planning by health care provider
organizations.
Lastly, given the varied geographic distribution of
health care resources, we must explore different
models that utilize local resources to meet local
needs. Health care providers must assume a greater
responsibility in this planning process. ■
REFERENCES
1. Butler JA, Rosenbaum S, Palfrey J: Ensuring access
to health care for children with disabilities. N Engl J Med
317:162-165, 1987.
2. Conroy JW: Medical needs of institutionalized men-
tally retarded persons: Perceptions of families and staff
members. Am J Ment Defic 89:510-514, 1985.
3. Crocker A, Yankauer A: Basic issues. Mental Re-
tardation 24:227-232, 1987.
4. Crocker A, Yankauer A: Symposium on community
health care services for adults with mental retardation.
Ment Retardation 25:189-242, 1987.
5. Friedman D, Kastner T, Pond W, O’Brien D:
Thyroid dysfunction in individuals with Down’s syn-
drome. Arch Intern Med (in press).
6. Garrard SD: Health services for mentally retarded
people in community residences: Problems and questions.
Am J Public Health 72:1226-1228, 1982.
7. Howard A: Utilization of health care services by per-
sons with mental retardation in Massachusetts. Washing-
ton, DC, Association on Mental Retardation, 1988.
8. Luckhardt J, Scagnelli J: Recommendations for im-
proving access to medical care for people with de-
velopmental disabilities. North Brunswick, New Jersey,
New Jersey Association for Retarded Citizens, 1988.
9. McDonald EP: Medical needs of severely de-
velopmentally disabled persons residing in the communi-
ty. Am J Ment Defic 90:171-176, 1985.
10. Merker EL, Wernsing DH: Medical care of the de-
institutionalized mentally retarded. Am Fam Physician
29:228-233, 1984.
11. Minihan PM, Dean D, Lyons CM: Providing care
to patients with mental retardation: A survey of physi-
cians in the state of Maine. AAMR Meeting, Chicago, IL,
1989.
12. Minihan PM: Planning for community physician
services prior to deinstitutionalization of mentally re-
tarded persons. Am J Public Health 76:1201-1205, 1986.
13. Rubin L: Health care needs of adults with mental
retardation. Ment Retardation 25:201-206, 1987.
14. Schor EL, Smalky, KA, Neff JM: Primary care of
previously institutionalized retarded children. Pediatrics
67:536-540, 1981.
15. Ziring PR, Kastner T, Friedman D, et al.: Provision
of health care for persons with developmental disabilities
living in the community; the Morristown model. JAMA
260:1439-1444, 1988.
822
NEW JERSEY MEDICINE
1991 MSNJ ANNUAL MEETING
The Board of Trustees of the Medical Society of New Jersey approved the Committee on
Annual Meeting’s recommendation that the 1991 Annual Meeting be held at the Trump Taj
Mahal Casino Resort in Atlantic City, on Sunday, April 28, through Wednesday, May 1, 1991.
The Merv Griffin’s Resorts Casino Hotel will participate with the headquarters hotel (Trump
Taj Mahal) for the 1991 Annual Meeting. The daily schedule follows:
Saturday, April 27, 1991
3:30 p.m. Board of Trustees' Meeting
Sunday, April 28, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
10:00 a.m. Educational Programs
11:30 a.m. Exhibits Open
1:30 p.m. House of Delegates
3:30 p.m. Reference Committee Meetings
Monday, April 29, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates (Election)
12:00 noon Golden Merit Award Ceremony and Reception
2:30 p.m. Reference Committee Meetings
5:00 p.m. JEMPAC Political Forum
5:45 p.m. JEMPAC Wine and Cheese Reception
6:30 p.m. Union County Medical Society Reception
Tuesday, April 30, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates
1:30 p.m. House of Delegates
7:00 p.m. Inaugural Reception and Dinner
honoring Doctor and Mrs. Joseph A. Riggs
Wednesday, May 1, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Educational Program
1:00 p.m. Board of Trustees’ Meeting
VOL. 87— NUMBER 10 OCTOBER 1990
823
HHUMDNJ NOTES HH
Record gift from individual. The
largest gift from an individual, $3.5
million, has been made to the Uni-
versity of Medicine and Dentistry
of New Jersey (UMDNJ) to sup-
port neurological genetic research
and endow a chair in neurology.
The gift, provided by William Dow
Lovett of Jacksonville, Florida,
through the Foundation of
UMDNJ, will provide for scholar-
ships, research, and patient ser-
vices. The award will establish the
William Dow Lovett Research
Fund to support research on
olivopontocerebellar atrophy, or
OPCA, a hereditary degenerative
disease of the nervous system. It
also will endow the William Dow
Lovett Professorship of Neurology.
Dr. Roger C. Duvoisin, professor
and chairman of neurology at
UMDNJ-Robert Wood Johnson
Medical School and an inter-
nationally renowned authority on
Parkinson’s disease and related
disorders, will be the first faculty
member to hold the chair.
High HIV -inf ection rate.
UMDNJ-LJniversity Hospital has
the highest seroprevalence rate of
HIV infection among 26 hospitals
in a nationwide study sponsored by
the Centers for Disease Control
(CDC). The 18-month CDC Sen-
tinel Hospital Surveillance Study
was designed to identify HlV-in-
fection rates among asymptomatic
patients in 39 hospitals in selected
urban areas, but only 26 had a suf-
ficient volume of HIV positive
samples to be included in the find-
ings. Seroprevalence of HIV infec-
tion was tested in blood samples
obtained from patients admitted
for reasons other than confirmed or
suspected HIV infection or con-
ditions frequently associated with
HIV infection. These reasons in-
clude unexplained fevers and sex-
ually transmitted diseases. Re-
sidual blood, collected for other
laboratory tests, was used in the
study. All patient identifiers —
other than age, sex, race, and
month of testing — were removed.
Nursing program going forward.
Middlesex County College (MCC)
and UMDNJ are moving ahead
with plans to offer a new joint nurs-
ing program at MCC this fall. The
decision to proceed followed an ap-
pellate court ruling reaffirming
UMDNJ’s right to participate in a
joint degree program. Fifty stu-
dents began classes at MCC in
September. Although final ap-
proval by the New Jersey Board of
Nursing was granted in June, ef-
forts to implement the proposed
joint progam were delayed by a
lawsuit. The July 31 ruling in favor
of the MCC/UMDNJ joint offering
enabled student enrollment to
proceed, although the decision
may be challenged in the state su-
preme court.
Designed for maximum flexibili-
ty, the Joint Associate Degree in
Nursing program incorporates two
entry tracks: an accelerated path
for licensed practical nurses and
other qualified health care person-
nel, and a conventional path for
high school graduates with no
previous health care related educa-
tion.
Students will be enrolled at
MCC and will be charged MCC
tuition and fees. Science and gen-
eral education courses will be of-
fered by MCC, while professional
nursing courses will be provided by i
UMDNJ nursing faculty. All |
clinical assignments will be con-
ducted at various Middlesex Coun-
ty acute health care facilities, as
well as at long-term care and other
specialized clinical facilities.
An associate in science (A.S.)
degree in nursing will be awarded i
jointly by the two institutions.
Graduates with the A.S. degree '
will be eligible to sit for the Na- ;
tional Council Licensure Exami-
nation for Registered Nurses
(NCLEX).
Researchers using artificial
mouth. In an effort to develop
longer lasting dental materials,
UMDNJ has purchased a com-
puter-controlled artificial mouth
that revolutionizes dental re-
search. The device — only the sec-
ond of its kind to be utilized in the
United States — significantly
speeds up testing new materials for i
dental products such as crowns,
bridges, and dentures. It was
purchased by the LIMDNJ-New
Jersey Dental School’s Biodental
Materials Laboratory with a
$267,000 grant from the National
Institutes of Health. According to
dental researchers, the device can
accomplish in two weeks what
would otherwise take five years.
The accuracy of the device’s chew-
ing motion and its exacting
measurement of the erosion of the
materials are technologically un-
paralleled. It will help develop ma-
terials that, potentially, can last
longer and perform better. That
will mean great savings for both
dentists and patients.
Stone Center first to gain
license. The Stone Center of New
Jersey, a state-of-the-art facility to
NOTEBOOK
824
NEW JERSEY MEDICINE
treat kidney stones, is the first in
the state to be licensed by the New
Jersey Department of Health. The
Center, a joint venture of UMDNJ-
University Hospital and a UMDNJ
affiliate, Saint Barnabas Medical
Center in Livingston, uses sophis-
ticated shock-wave technology to
eliminate kidney stones in place of
traditional major surgery. Located
at UMDNJ’s Newark campus, the
Center has treated more than 3,000
patients since it opened in October
1987 as a demonstration project.
One of three such projects in the
state, the Stone Center has been
licensed by the state under the
guidelines set for an ambulatory
care facility. □ Stanley S. Bergen,
Jr, MD
■HMSNJ AUXILIARY**
At the 1990 Annual Session of
the AMA Auxiliary, the House of
Delegates adopted a resolution
sponsored by MSNJA. The resolu-
tion that became the policy of the
AMAA encourages state and coun-
ty auxiliaries to work with their
legislators to draft and support
legislation to deal more severely
with those who operate boats or
other powered vessels while under
the influence of alcohol and other
mind-altering substances.
In addition to the New Jersey
resolution, the House of Delegates
adopted eight other health-related
resolutions resulting in the follow-
ing policies: The AMAA en-
courages auxiliaries to urge physi-
cians to ban smoking in offices; to
work with educational associations
and schools to encourage the de-
velopment of mathematics and sci-
ence skills of young people to in-
crease the pool of qualified appli-
cants to health professions educa-
tional programs; to support pro-
grams to educate the public on the
dangers of hearing loss due to loud
noise; to support educational and
legislative programs to improve en-
forcement of seat belt laws, to im-
prove seat belt design, and to im-
prove instructions to parents con-
cerning installation, use, certifica-
tion, and recall of child safety
seats; to promote the development
of programs at police academies to
teach interviewing skills and cor-
rect methods of dealing with chil-
dren who are victims of child
abuse; to support programs that
increase awareness of the far-
reaching effects of the U.S./Mexico
border health problem and their
potential impact on the health of
Americans; and to increase public
awareness of the need for a com-
prehensive school health education
program for grades kindergarten
through 12. The House of Del-
egates also adopted a resolution
encouraging auxiliaries to work
with resident physicians’ spouse
groups to establish programs that
will help create a solid family base
within the medical community
and ensure membership of resident
physicians’ spouses at all levels of
the federation after residency.
On the final day of the conven-
tion, Norma Skoglund of Oregon
was installed as the 1990-1991
AMAA president. In her inaugural
address, Mrs. Skoglund discussed
the volunteer efforts of the medical
community and the need for phy-
sicians and their spouses to take
time to see the value of their ser-
vice.
“Volunteerism always has made
a difference when health and medi-
cal issues have troubled America,”
she said. “At the turn of the cen-
tury, the enemy was yellow fever
and cholera. Then TB and polio;
now cancer and AIDS.” And dur-
ing all these years, noted Mrs.
Skoglund, volunteers, including
auxiliary members, have stood by
physicians and researchers by rais-
ing funds for medical research and
by supporting community health
programs and education projects.
The president added, “Physicians
across the country also are volun-
teering their time not only for
health and medical service but for
community programs such as
school boards, the arts, sports pro-
grams, and programs for the elder-
ly and the homeless. Unfortunate-
ly, the public has not always seen
the contributions physicians make
outside the office setting. As physi-
cians’ spouses and volunteers in
our medical auxiliaries, we can
help dispel some of the criticism
surrounding the medical com-
munity. By working with the
media to highlight some of the vol-
unteer efforts of physicians and
their spouses in the community, I
believe we will be able to foster
better public relations for the
medical profession.” □ Marion H.
Geib
HI PLACEMENT FILE ■■
The following physicians have
written to the executive offices of
MSNJ seeking information on pos-
sible opportunities for practice in
New Jersey. The information has
been supplied by the physicians. If
you are interested in any further
information concerning these phy-
sicians, we suggest you make in-
quiries directly to them.
INTERNAL MEDICINE
Anan Adnan Faidi, MD, 30 Charles St.
W, Apt. 1717, Toronto, Ontario, IM4Y
1R5 Canada. Jordan 1983. Board certi-
fied. Also, board eligible (ENDO-
CRIN). Group. Available.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner-
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital-based. Available.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Wood-
side Ave., Trenton, NJ 08618. Rutgers
1980. Board certified. Part time or full
time. Available.
SURGERY
Donna Vecchione, MD, 27700 Bishop
Park Dr., 4025, Willoughby Hills, OH
44092. SUNY-Stony Brook 1985.
Board eligible. Partnership, solo,
multispecialty group. Available.
VOL. 87— NUMBER 10 OCTOBER 1990
825
r
PHILADELPHIA HEART INSTITUTE
of Presbyterian Medical Center
I Cardiology
Update it
designed for the physician and provides an intensive
survey of the current status of clinical cardiology . . .
Wednesday, November 7, 1990
Recent Advances in Diagnosis and Treatment of Acute MI
Moderator: William J. Untereker, M.D.
3:00-3:30
Typical and atypical clinical findings in
acute myocardial infarction
Charles Gottlieb , M.D.
3:30-4:00
Early management: Thrombolytic agents,
heparin, beta-blockers, nitrates, aspirin,
etc Which drugs and for whom?
William J. Untereker, M.D.
4:00-5:00
Case Presentations
Panel Discussion
Marie-Noelle Langan, M.D.
William Corin, M.D.
Norman Feinsmith , M.D.
Charles Gottlieb, M.D.
Mariell Jessup, M.D.
Howard Rosner, D.O.
William F. Santamore , Fh.D.
SB Case Presentations and Panel Discussions
■ CME Credits*
■ No Registration Fee
H Call for Reservation 662-8627
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
‘The Philadelphia Heart Institute at Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
Presbyterian Medical Center designates this continued medical education activity for 2 credit hours in Category I of
the Physicians’ Recognition Award of the American Medical Association and the Pennsylvania Medical Society
Membership requirement. Nine sessions, 18 credits.
V —
826
NEW JERSEY MEDICINE
CONTINUING EDUCATION
ANESTHESIOLOGY
November
20 Meeting
6- 9 P.M. — Ramada Inn, Clark
(New Jersey State Society
of Anesthesiologists)
CARDIOLOGY
November
20 Current Strategy in the
Management of Arrhythmias
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
December
11 What’s New in Heart Failure
9-10 A M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
13 Newer Cardiac Drugs
8-9 P.M. — Centrastate Medical
Center, Freehold
(AMNJ)
DERMATOLOGY
November
13 Dermatology Meeting
7- 9 P.M. — Schering Corporation,
Kennilworth
(Dermatological Society of
New Jersey)
December
11 Dermatology Meeting
7- 9 P.M. — Schering Corporation,
Kennilworth
(Dermatological Society of
New Jersey)
INFECTIOUS DISEASE
November
6 Diagnosis and Treatment of
AIDS
8- 9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ and NJDOH)
6 Psychotherapy with AIDS
Patients
8:30-10 A.M. —Elizabeth General
Medical Center, Elizabeth
(Elizabeth General
Medical Center)
8 Issues and Perspectives:
Neuropsychiatric and
Psychosocial Aspects of AIDS
8:30 A.M. -3:15 P.M. —Clarion
Hotel, Edison
(UMDNJ)
12 Identification and Management
of HIV Infection
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
December
7- HIV and the Health
8 Professional
All day — LlMDNJ-Newark
(UMDNJ)
MEDICINE
November
1- Sinus Endoscopy
2 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
3 Obesity Update
8 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
4 Recent Advances in Colony-
Stimulating Factors
9 A.M.-l P.M. — Ramada
Renaissance, East Brunswick
(UMDNJ)
6 Grand Rounds
13 8:30-10 A.M. —Elizabeth General
20 Medical Center, Elizabeth
27 (Elizabeth General
Medical Center)
7 Emergency Medical Care
10:30-11:30 A. M.— St. Mary’s
Hospital, Passaic
(AMNJ)
7 Newer Concepts in Asthma
Management
1:30-2:30 P.M.— HIP/RCHP,
New Brunswick
(RCHP and AMNJ)
8 Annual Meeting
8 A.M. -4 P.M. —Hyatt Regency,
New Brunswick
(NJ Society of Critical Care
Medicine)
8 Diabetic Nephropathy
11 A.M. -12 Noon — Hunterdon
Developmental Center, Clinton
(AMNJ)
1 1 Diabetic Nephropathy
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
12 Hyperalimentation
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ)
12 Renal and Pancreatic
Transplantation Update
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
13 Management Symposium
7-9 P.M. — Schering Corporation,
Kenilworth
(Dermatological Society of
New Jersey)
14 Coding Workshop
9 A.M. -3 P.M.— MSNJ
Headquarters, Lawrenceville
(Urology Society of New Jersey)
14 Fall Refresher Course
8 A.M. -4 P.M.— Sheraton Hotel,
Woodbridge
(NJ Academy of Family
Physicians)
14 Cocaine Express
9:15 A.M. -4:30 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation)
14 Proper Use of Endoscopy
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
14 Diabetic Nephropathy
1:30-2:30 P.M. — Roosevelt
Hospital, Metuchen
(AMNJ)
15 Partial Hospitalization and Its
Psychotherapeutic Role
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation)
15- Third Conference on
17 Radioimmunodetection and
Radioimmunotherapy of Cancer
All day — Princeton University,
Princeton
(Center for Molecular Medicine
and Immunology)
VOL. 87— NUMBER 10 OCTOBER 1990
827
£D
Debaoh
Heatond Lunq
Center
CLINICAL UPDATE
PULMONARY MEDICINE
November 28, 1990
I
COURSE DESCRIPTION
The 7th Annual Clinical Update is designed to provide family practitioners, general internists, pulmonologists, and othe
interested physicians with an updated review of pulmonary disorders which are commonly encountered in clinical practice (
as well as certain disorders which are of current topical interest. The program has been carefully selected to ensure a gooc
blend of established and new methods and approaches to pulmonary diseases.
The morning session will provide participants with systematic approaches to tuberculosis in the HIV era, asthma, chronic
obstructive pulmonary disease and sleep apnea.
The afternoon session will present current concepts in the staging and surgical treatment of lung cancer. A special
lecture will focus on the expectations of surgical treatment of lung cancer. The role of computed tomography in assessment
will be emphasized. Session will conclude with a discussion of postoperative pulmonary complications and their prevention.
Throughout the day, emphasis will be placed on risk factors, natural history, early detection, prognosis, newer diagnostic
techniques and new methods of therapy.
A.M.
8:00
8:50
9:00
10:00
11:00
11:15
12:00
MORNING SESSION
Registration
Welcome- Vladir Maranhao, M.D
“HIV Infection: The Dominant Face of Tuberculosis”
Lee B. Reichman, M.D.
“Asthma: New Strategies in Diagnosis and Treat-
ment"
Clifford W. Zwillich, M.D.
Coffee Break
"Evaluation and Therapy of COPD”
David M.F. Murphy, M.D.
“Recognition and Management of Sleep Apnea"
Clifford W. Zwillich, M.D.
GUEST FACULTY
CLIFTON F. MOUNTAIN, M.D., Professor of Surgery, Department
of Thoracic Surgery, University of Texas School of Medicine at
Houston, University of Texas Cancer Center, M.D. Anderson Hospi-
tal and Tumor Institute, Houston, Texas.
ROBERT D. PUGATCH, M.D., Associate Professor of Radiology,
Department of Radiology, Harvard Medical School; Director of
Thoracic Radiology, Brigham and Women's Hospital, Boston,
Massachusetts.
LEE B. REICHMAN, M.D., Professor of Medicine, Director of
Pulmonary Division, University of Medicine and Dentistry of New
Jersey, Newark, New Jersey.
P.M
12:50
1:40
2:40
3:30
AFTERNOON SESSION
Luncheon
Clara Falk Franks Lecture-“Stagmg of Lung Cancer
in 1990”
Clifton F. Mountain, M.D.
“Computed Tomography in Lung Cancer"
Robert Daniel Pugatch, M.D.
Coffee Break
CLIFFORD W. ZWILLICH, M.D., Professor of Medicine and Chief,
Pulmonary and Critical Care Medicine, Pennsylvania State Univer-
sity College of Medicine, Hershey, Pennsylvania.
LOCAL FACULTY
FEIERSTEIN, M.D., Program
MERVYN FEIERSTEIN, M.D., Program Director, Attending
Pulmonologist, Department of Pulmonary Medicine, Deborah Heart
and Lung Center, Browns Mills, New Jersey.
3:45 “Surgical Treatment of Non-Small Cell Carcinoma of
the Lung”
Clifton F Mountain, M.D.
4:45 “Reducing the Risk of Postoperative Pulmonary
Complications"
Mervyn Feierstein, M.D.
5:20 Adjourn
VLADIR MARANHAO, M.D., Clinical Associate Professor of Medi-
cine, UMDNJ-Robert Wood Johnson Medical School, New Bruns-
wick, New Jersey; Vice President, Medical Affairs, Deborah Heart
and Lung Center, Browns Mills, New Jersey.
DAVID M.F. MURPHY, M.D., Program Chairman, Department of
Pulmonary Medicine, Deborah Heart and Lung Center, Browns
Mills, New Jersey.
SEVENTH ANNUAL CLINICAL UPDATE IN PULMONARY MEDICINE
Wednesday, November 28, 1990
Sponsored by:
Deborah Heart and Lung Center
) Browns Mills, New Jersey
CSIL/ (609) 893-6611
NAME
ADDRESS
CITY/STATF
7IP
SPECIALTY
PHONE t )
Tuition: All participants, fee includes luncheon and refreshments—
$95.00.
A check in the amount of $95.00 payable to Deborah Heart and
Lung Center should accompany this application. Mail to Pulmonary
Department, Deborah Heart and Lung Center, Browns Mills, N.J.
08015.
Due to limited seating capacity, early registration is strongly advised.
Registration deadline— Wednesday, November 14, 1990.
For Program Information please call:
Accreditation: Deborah Heart and Lung Center designates that this
continuing medical education offering meets the criteria for 7.0
credit hours in category 1 of the Physician's Recognition Award of
the American Medical Association.
This program has been reviewed and is acceptable for 7.0
prescribed hours by the American Academy of Family Physicians.
Mrs. Diane Colby (609) 893-6611.
828
NEW JERSEY MEDICINE
17 The Breast
8 A.M.-2 P.M. — Sheraton Poste
Inn, Cherry Hill
( Cooper Hospital/University
Medical Center)
17 Office Computer Seminar
8 A.M.-4 P.M. — Hyatt Regency
Hotel, New Brunswick
(MSNJ and AMNJ)
17 Slide Seminar: Bone Marrow
and Spleen
9 A.M.-l P.M. — Robert Wood
Johnson Medical School,
New Brunswick
(NJ Society of Pathologists)
20 Chronic Epstein-Barr Virus
8- 9 A. M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
21 Diabetic Nephropathy
9- 10 A. M. — Warren Hospital,
Phillipsburg
26 Sports Medicine
5:30-8 P.M. —Robert Wood
Johnson Medical School,
New Brunswick
(UMDNJ)
27 Parkinson Disease
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
28 Clinical Update in Pulmonary
Medicine
8 A.M. -5:20 P.M. — Deborah Heart
and Lung Center, Browns Mills
(Deborah Heart and Lung Center)
28 New Practice Program
8 A.M. -3:30 P.M.— MSNJ
Headquarters, Lawrenceville
(MIIENJ)
30 Hypnosis in Couples and Family
Therapy
8:30-4:30 P.M. — UMDNJ, Newark
(UMDNJ)
30 Sickle Cell Disease
12 Noon-1 P.M. — Mercer Medical
Center, Trenton
(Mercer Medical Center)
December
1 39th Annual Clinical Meeting
8:30 A.M. -4:30 P.M.— Robert
Wood Johnson Medical School,
Piscataway
(American College of Surgeons
and AMNJ)
I Grand Rounds
II 8:30-10 A.M. — Elizabeth General
18 Medical Center, Elizabeth
15 (Elizabeth General
Medical Center)
1 Nephrotoxicity of Common
Drugs
8-9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
4 Case Presentation
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
5 Septic Shock
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
5 Clinical Abstract Meeting
1:30-5 P.M. — The Manor,
West Orange
(Oncology Society of New Jersey)
5 Legal Liability for T.D.
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
12- C02 Laser Surgery
13 7:30 A.M. -4:30 P.M. —UMDNJ,
Newark
(UMDNJ)
12 Critical Care Topics
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
12 Prevention of Lower Extremity
Amputations
1:30-2:30 P.M. — Roosevelt
Hospital, Metuchen
(AMNJ)
13- Sinus Endoscopy
14 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
13 Doctor/Patient Sex and
Medicolegal Issues
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
13 New Developments in
Emergency Medical Care in
New Jersey
12 Noon-1 P.M. — Community
Medical Center, Toms River
(AMNJ)
18 Evaluation of Cholesterol
Awareness
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
19 Aspiration Syndrome in the
Mentally Retarded
9-10 A.M. — Warren Hospital,
Phillipsburg
(AMNJ)
19 Strokes
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
21 Prevention of Lower Extremity
Amputations
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ and NJDOH)
OBSTETRICS/GYNECOLOGY
November
2 Semi-Annual Meeting
8 A.M. -5 P.M. — Sheraton
Meadowlands Hotel, Secaucus
(NJ Obstetrical and
Gynecological Society)
4- Fifth Annual Issues and
7 Controversies in Ob/Gyn
7 A.M.-l P.M. — Contemporary
Hotel, Walt Disney World
(UMDNJ)
17 The Breast
8 A.M. -2 P.M. — The Sheraton
Poste Inn, Cherry Hill
( Cooper Hospital/University
Medical Center)
December
13- C02 Laser Applications
15 in Ob/Gyn
8 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
ONCOLOGY
November
15 Tumor Board Conference
12 Noon-1 P.M. —Newcomb
Medical Center, Vineland
(AMNJ)
30 Breast Cancer: Risks and
Controversies
8:45 A.M. -4:15 P.M. — UMDNJ-
Robert Wood Johnson Medical
School, New Brunswick
(UMDNJ)
December
13 Meeting: Head and Neck
Oncology Section
6:30-9:30 P.M.— The Hyatt,
New Brunswick
(AMNJ)
SPECIAL ISSUE:
Medical Research in
New Jersey
November 1990
'OL. 87— NUMBER 10 OCTOBER 1990
829
fUJlf? Hahnemann Department of Medicine
University
GRAND ROUNDS
WEDNESDAYS
8:30 a. m. -9:30 a.m.
October-December, 1990
OCTOBER, 1990
October 3, 1990
PITUITARY ADENOMAS: DIAGNOSIS AND TREATMENT
Peter Snyder, MD
Associate Professor of Medicine
Division of Endocrinology
University of Pennsylvania School of Medicine
Philadelphia, PA
October 10, 1990
CHANGING PATTERNS OF AIDS AND THE LUNGS
Philip C. Hopewell, MD
Professor of Medicine
University of California, SF
Chief, Chest Service, San Francisco General Hospital, CA
October 17, 1990
DIVISION OF CARDIOLOGY CLINICAL RESEARCH:
CARDIAC IMAGING
Eric L. Michelson, MD
Professor of Medicine
Director, Division of Cardiology
Hahnemann University
October 24, 1990
CARDIAC REMODELING: CLINICAL IMPLICATIONS
AND THERAPEUTIC OPTIONS
Gervasio A. Lamas, MD
Assistant Professor of Medicine
Harvard Medical School, Boston, MA
October 31, 1990
DIABETIC NEPHROPATHY
Eli A. Friedman, MD
Professor of Medicine
Chief, Division of Renal Disease
SUNY Health Science at Brooklyn, NY
NOVEMBER, 1990
November 7, 1990
STEROID ABUSE IN THE ATHLETE
Robert Cantu, MD
Chairman of Surgery
Director, Services of Sports Medicine
Emerson Hospital, Concord, MA
Consultant, Sports Medicine Committee
USA American Boxing Federation
P
November 14, 1990
CONTROVERSIES IN NON-CARDIAC CHEST
PAIN (Gastro-Esophageal Reflux, Achalasia)
Sidney Cohen, MD
Professor and Chairman of Medicine
Temple University School of Medicine
Philadelphia, PA >,
November 21 , 1990
AGING OF THE SKIN
Richard L. Speilvogel, MD
Professor of Medicine and Dermatology
Director, Division of Dermatology
Hahnemann University
November 28, 1990 I
MEDICAL MANAGEMENT OF DEPRESSION AND ANXIETY
Gary Tollefson, MD, PhD
Associate Professor of Psychiatry
University of Minnesota, MN
Jonathan O. Cole, MD
Chief, Psychopharmacology Program
McLean Hospital, Belmont, MA
DECEMBER, 1990
December 5, 1990
PTCA VS BYPASS GRAFT SURGERY FOR CORONARY
ARTERY DISEASE
William S. Frankl, MD
Vischer Professor of Medicine and Chairman,
Department of Medicine
Director, Likoff Cardiovascular Institute
Hahnemann University
December 12, 1990
ABNORMALITIES OF THROMBOSIS AND THROMBOEMBOLISN
Daniel Deykin, MD
Chief of Medicine, Director, Health Services
Research and Development
Boston VA Medical Center, MA
December 19, 1990
DIVISION OF PULMONARY MEDICINE AND CRITICAL CARE
Edward Schulman, MD
Associate Professor of Medicine
Director, Division of Pulmonary and Critical Care Medicine
Hahnemann Universtiy
WEDNESDAY MEDICAL SEMINAR SERIES
8:30 a.m. -3:30 p.m.
October 10, 1990 November 28, 1990
AIDS TREATMENT MEDICAL MANAGEMENT OF
DEPRESSION AND ANXIETY
December 12, 1990
November 7, 1990 ABNORMALITIES OF THROMBOSIS
MEDICINE IN ATHLETICS AND THROMBOEMBOLISM
Seminar Directors:
William S. Frankl, MD
Professor of Medicine
and Chairman
Department of Medicine
Allan B, Schwartz, MD
Professor of Medicine
Director, Continuing
Medical Education for the
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd FI. New College Bldg.
Hahnemann University
15th Street Entrance
15th & Vine Streets
Philadelphia, PA
As an organization accredited by the Accreditation Council for Continuing Medical
Education (ACCME), Hahnemann University designates this continuing medical
education activity as Category 1 of the Physician’s Recognition Award of the
American Medical Association. One credit hour may be claimed for each hour
of participation by the individual physician.
For Information, call the Office of Continuing Education at (215) 448-8263
830
NEW JERSEY MEDICINE
14 Cancer Committee/Tumor
Board Conference
11 A.M.-12 Noon— Wallkill Valley
Hospital, Sussex
(Wallkill Valley Hospital and
AMNJ)
27 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(AMNJ)
PEDIATRICS
November
13 The Wayward Adolescent
8:30-10 A. M. — Elizabeth General
Medical Center
(Elizabeth General
Medical Center)
December
7- Pediatric Advanced Life
8 Support
7:30 A. M. -3:30 P.M. —Shore
Memorial Hospital, Somers Point
(AMNJ)
PSYCHIATRY
November
1 Research Update: Adolescence
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation)
6 Psychiatry Grand Rounds
13 8:30-10 A. M. — Elizabeth General
20 Medical Center, Elizabeth
27 (Elizabeth General
Medical Center)
7 Treatment Plan and Goal
Setting in Psychiatric Patients
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
8 Psychopathology as Predictor of
Treatment Outcome in
Alcoholics
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
14 Cocaine Express
All day — Carrier Foundation,
Belle Mead
(Carrier Foundation)
15 Partial Hospitalization and its
Psychotherapeutic Role
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
21 Early Office Recognition of
Depression
10:30-11:30 A. M. — St. Mary’s
Hospital, Passaic
(AMNJ)
27 Adoption: Psychological Issues
8:30-10 A. M. — Elizabeth General
Medical Center, Elizabeth
(Elizabeth General
Medical Center)
30 Treatment of Borderline
Personality Disorder with Self-
Destructive Behavior
10-11 A M. — Marlboro Psychiatric
Hospital, Marlboro
(AMNJ)
December
4 Psychiatry Grand Rounds
11 8:30-10 A. M. — Elizabeth General
18 Medical Center, Elizabeth
25 (Elizabeth General
Medical Center)
6 Therapist Response to the
Suicide of a Patient
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
8 Fragmentation of the Self in
Schizophrenia
8:30-10 A.M. — Elizabeth General
Medical Center, Elizabeth
(Elizabeth General
Medical Center)
11 MICA Patients
8:30-10 A.M. — Elizabeth General
Medical Center, Elizabeth
(Elizabeth General
Medical Center)
13 Borderline Syndrome: Doctor/
Patient Sex and Medicolegal
Issues
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
20 Psychotherapeutic Approaches
for Healing the Shame and
Silence of the Sexually Abused
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
RADIOLOGY
November
15 Radiology Meeting
Saint Barnabas Medical Center,
Livingston
(Radiology Society of
New Jersey/ AMNJ)
December
20 Radiology Meeting
Saint Barnabas Medical Center,
Livingston
(Radiology Society of
New Jersey/ AMNJ)
UROLOGY
November
8 Grand Rounds
15 7-9 P.M. — Robert Wood Johnson
29 Medical School, Piscataway
(UMDNJ)
December
6 Grand Rounds
13 7-9 P.M. — Robert Wood Johnson
20 Medical School, Piscataway
(UMDNJ)
ARE YOU MOVING?
If so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
VOL. 87— NUMBER 10 OCTOBER 1990
831
Acupuncture & Electro-Therapeutics
in Clinical Practice
New York State Boards of Medicine & Dentistry 25-
hour accredited seminar & workshop on latest theories
& techniques of manual & electro-acupuncture, TENS
& simple non-invasive diagnostic methods (including
cardio-vascular, neuromuscular, central nervous systems
& “Bi-Digital O-Ring Test”), applicable towards 300-
hour requirement for certification to practice
acupuncture, will be given periodically for licensed clini-
cians (with or without prior training) on 3- day weekends
(Fri-Sun) of Dec. 14-16, 1990, and Jan. 25-27, 1991, etc.,
at Milford Plaza Hotel, 45th St. & 8th Ave., New York
City.
The 6th Annual International Symposium on
Acupuncture & Electro-Therapeutics will be held at
Columbia University, School oflnternational Affairs, 420
W. 118th St., N.Y. City, during October 25-28, 1990.
These meetings are co-sponsored by the International
College of Acupunture & Electro-Therapeutics & its of-
ficial journal, Acupuncture & Electro-Therapeu-
tics Research. The International Journal (published by
Pergamon Press & indexed in 15 major indexing per-
iodicals, including Index Medicus), Heart Disease Re-
search Foundation; NY Pain Center; Electrical Engi-
neering Dept., Manhattan College; Nordic Medical
Acupuncture Society (Scandinavia); Schmerz
Therapeutische Kolloquium (West Germany); Japan Bi-
Digital O-Ring Test Assn.; Accredited toward
Acupuncture Certification to practice acupuncture.
Eligible for AMA CME Cat. I credit (about 40 credit-
hours for the Symposium).
For information on meetings or submission or presen-
tations of papers, contact Symposium Chairman, Prof.
Y. Omura, M.D., Sc.D., 800 Riverside Drive (8-1) New
York, NY 10032 Tel: (212) 781-6262 (10 am to 10 pm 7
days a week) or (212) 928-0658, Co-chairman, Prof. A.W.
Cook, MD (516) 877-1821, or Bro. Michael Losco (212)
920-0162.
SEXUAL FUNCTION CENTER
THOMAS JEFFERSON UNIVERSITY HOSPITAL
AND
CONTINUING MEDICAL EDUCATION
JEFFERSON MEDICAL COLLEGE
PRESENT
Newer Concepts
and
Therapy of
Impotence
Friday, November 16, 1990
Jefferson Alumni Hall
Jefferson Medical College
Philadelphia, PA
Stanley N. Cohen, M.D., Director
FOR ADDITIONAL INFORMATION, CALL:
Continuing Medical Education, Jefferson Medical College
(215) 955-6992
YOCON'
YOHIMBINE HCI
Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.
Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone
Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it. however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.
Indications: Yocon 8 is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac
Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications
Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history Nor should it be used in coniunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.
Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.1 2 Also dizziness,
headache, skin flushing reported when used orally.1'3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence.1'3 4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to 'h tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon58 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000's NDC
53159-001-10.
References:
1. A. Morales et al. , New England Journal of Medi-
cine: 1221 . November 12, 1981 .
2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed., p. 176-188.
McMillan December Rev. 1/85.
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales et al. , The Journal of Urology 128:
45-47, 1982.
Rev. 1/85
AVAILABLE AT PHARMACIES NATIONWIDE
PALISADES
PHARMACEUTICALS, INC.
219 County Road
Tenafly, New Jersey 07670
(201) 569-8502
1-800-237-9083
832
NEW JERSEY MEDICINE
George Babcock, Jr. Born in
Newark on April 26, 1916, George
Babcock, Jr., MD, died on Febru-
ary 26, 1990, at the age of 73. Dr.
Babcock earned his medical degree
from Western Reserve University
School of Medicine, Cleveland,
Ohio, in 1947, received his New
Jersey medical license the follow-
ing year, and served an internship
at East Orange General Hospital.
Board certified in allergy and im-
munology, Dr. Babcock main-
tained a private practice in East
Orange and Wayne. Dr. Babcock
was on the staff at the former Riv-
erside Hospital, Boonton, and at
Chilton Memorial Hospital,
Pompton Plains. He was employed
by Schering Corporation, Bloom-
field, and by Ives Laboratories,
Inc., New York. Dr. Babcock
served in the United States Na-
tional Reserves from 1943 to 1945.
Dr. Babcock was a fellow of the
American College of Allergy, of the
American Academy of Allergy, and
of the American Geriatric Society.
In addition, Dr. Babcock was a
member of our Morris County
component and of the American
Medical Association.
Anselmo J. Brache. General
surgeon, Anselmo Joseph Brache,
MD, died on June 21, 1990, at the
age of 59. Born in the Dominican
Republic on March 12, 1931, Dr.
Brache received his medical degree
from Santo Domingo University
Faculty of Medicine in 1955. After
serving an internship at St. Eliza-
beth Hospital and residencies at
Bayonne Hospital, Jersey City
Medical Center, and Metropolitan
Hospital Center, New York, Dr.
Brache received his New Jersey
medical license in 1966. Dr. Brache
had his private surgical practice in
Bayonne for over 25 years and was
affiliated with Bayonne Hospital.
For many years, Dr. Brache was a
member of the American Medical
Association and of our Hudson
County component.
Louis E. De Simone. Asbury
Park resident Louis Edward De
Simone, MD, died July 2, 1990, at
the age of 72. Born in Boston on
October 31, 1917, Dr. De Simone
received his medical degree from
St. Louis University School of
Medicine in 1943 and his New Jer-
sey medical license in 1946. A gen-
eral practitioner, Dr. De Simone
had his practice in Asbury Park for
many years. He was affiliated with
several area hospitals: Monmouth
Medical Center, Long Branch, and
Jersey Shore Medical Center, Nep-
tune. Dr. De Simone served as a
Wall Township school physician
for 35 years and as a school phy-
sician for Mount Carmel Parochial
School. Dr. De Simone was a phy-
sician for Central Railroad of New
Jersey. Dr. De Simone was a medi-
cal examiner for numerous in-
surance companies. Dr. De Simone
served in the United States Army
during World War II from 1944 to
1945 as captain. Dr. De Simone
was a member of the American
Medical Association and of our
Monmouth County component.
Young M. Kim. Pathologist
Young Mook Kim, MD, died on
October 17, 1989, at the age of 74.
Born in Korea on August 15, 1915,
Dr. Kim earned his medical degree
from Tokyo Medical College,
Japan, in 1941 and received his
Japan medical license in 1942 and
his Korean medical license in 1952.
Dr. Kim served an internship and
residency at Tokyo Medical Col-
lege and maintained a private
practice in Korea before coming to
the United States. After serving an
internship at St. Mary’s Hospital,
Passaic, and residencies at St.
Mary’s Hospital, The Moun-
tainside Hospital, Montclair, and
General Hospital Center at
Passaic, Dr. Kim received his New
Jersey medical license in 1963. Dr.
Kim was affiliated with Presby-
terian Hospital, Newark, and
Newark Beth Israel Medical
Center and was a professor of
pathology at the School of Den-
tistry, Fairleigh Dickinson Univer-
sity, Rutherford. Dr. Kim served
as captain in the Korea Medical
Corps from 1952 to 1953. Dr. Kim
was a member of the Korea Medi-
cal Society, of the Japan Medical
Society, of our Essex County com-
ponent, and of the American Medi-
cal Association.
Harry B. Lochhead. A member
of our Gloucester County compo-
nent, Harry Burton Lochhead,
MD, died on July 14, 1990, at the
age of 83. Born in West Pittston,
Pennsylvania, on April 5, 1907, Dr.
Lochhead earned his medical
degree from Temple University
School of Medicine, Philadelphia,
in 1935, and his New Jersey medi-
cal license in 1954. Board certified
in clinical pathology and patho-
logic anatomy, Dr. Lochhead prac-
ticed in Woodbury and was af-
filiated with Underwood-Memorial
Hospital, Woodbury. In the early
1950s, Dr. Lochhead coauthored
several articles. Dr. Lochhead was
a member of the American Medi-
cal Association, an emeritus mem-
ber of the Medical Society of New
i/OL. 87— NUMBER 10 OCTOBER 1990
833
Jersey, and a fellow of the Ameri-
can Society of Clinical Pathology.
Dr. Lochhead was a major in the
U.S. Army from 1942 to 1946.
Helen L. Miller. Born in Corn-
vallis, Oregon, on June 27, 1896,
Helen Lovena Miller, MD, died on
June 18, 1990, at the age of 93. In
1926, Dr. Miller earned her medi-
cal degree from the University of
Oregon Medical School, Portland.
Dr. Miller received her New Jer-
sey, New York, and Oregon medi-
cal licenses. Dr. Miller interned at
New York Infirmary-Beekman
Downtown Hospital, New York. A
general practitioner, Dr. Miller
had her practice in Kinnelon and
was affiliated with Kinnelon Medi-
cal Center prior to her retirement
in 1989. She was a member of our
Morris County component, of the
New York County Medical So-
ciety, and of the American Medical
Association. Dr. Miller was past-
president of the New York State
Women’s Medical Society.
Robert T. Miller. Word has
been received of the death of Rob-
ert Thomas Miller, MD, on June 3,
1990. Born on August 22, 1926, in
Bayonne, Dr. Miller received his
medical degree from George Wash-
ington University School of Medi-
cine, Washington, DC, in 1953. Dr.
Miller received his Connecticut
medical license in 1954, his New
Jersey medical license in 1957, and
his New York medical license in
1959. Dr. Miller interned at
Hackensack Medical Center and
served his residency at Yale-New
Haven Hospital, New Haven, Con-
necticut. Dr. Miller practiced ob-
stetrics-gynecology in Oradel and
Cape May Court House and was
affiliated with Hackensack Medi-
cal Center; Pascack Valley Hospi-
tal, Westwood; Valley Hospital,
Ridgewood; and Burdette Tomlin
Memorial Hospital, Cape May
Court House. Dr. Miller served in
the United States military from
1944 to 1946. Dr. Miller was a
member of our Bergen County and
Cape May components and of the
AMA. Dr. Miller also was a fellow
of the American College of Ob-
stetricians and Gynecologists.
Harry M. Poppick. One of the
founding physicians of Bayshore
Community Hospital, Holmdel,
Harry M. Poppick, MD, died June
24, 1990, at the age of 73. Born in
New York City on June 5, 1917, Dr.
Poppick attended the University of
Colorado School of Medicine, earn-
ing his medical degree in 1951. Dr.
Poppick received his New Jersey,
Colorado, and Arizona medical
licenses. Dr. Poppick interned at
Metropolitan Hospital Center,
New York City. Prior to relocating
to Keyport over 30 years ago, Dr.
Poppick lived in Brooklyn and
Denver. Dr. Poppick was affiliated
with several area hospitals: River-
view Medical Center, Red Bank;
Monmouth Medical Center, Long
Branch; and Bayshore Community
Hospital. In addition to his private
general practice, Dr. Poppick was
a Madison Township school phy-
sician and a professor of family
practice at UMDNJ-Robert Wood
Johnson Medical School, New
Brunswick. Dr. Poppick served on
the Raritan Township Board of
Health as vice-president; and on
the Bayshore Community Hospital
Board of Trustees since 1985. Dr.
Poppick was a fellow of the Ameri-
can Academy of General Practice
and a member of our Monmouth
County component. An avid read-
er, Dr. Poppick was a contributing
book reviewer for NEW JERSEY
MEDICINE. In 1987, Dr. Poppick
was named most distinguished
physician at Bayshore Community
Hospital. He was a first lieutenant
in the U.S. Army, serving in the
Chemical Warfare Service from
1942 to 1947 and in the Medical
Corps Reserve from 1950 to 1952.
D. Joseph Terreri. After a short
illness, D. Joseph Terreri, MD,
died on April 13, 1990, at the age
of 82. Dr. Terreri was born on
January 19, 1908, in Morristown.
In 1934, Dr. Terreri received his
medical degree from Loyola Uni-
versity School of Medicine, Chi-
cago, and his New Jersey medical
license. Dr. Terreri received his
obstetrics training at the former
Margaret Hague Maternity Hospi-
tal and at St. Francis Hospital,
both in Jersey City. Dr. Terreri
practiced obstetrics and gyne-
cology in Morristown for many
years until his retirement in 1980.
He was affiliated with the former
All Souls Hospital, Morristown, P
and with St. Clare’s Riverside
Medical Center, Denville. For 17
years, Dr. Terreri was a physician
for the Morris County Jail. Dr. 11
Terreri was a member of our 11
Morris County component and of
the American Medical Association. f
He received the Golden Merit 1
Award from the Medical Society of '
New Jersey. Terreri served as cap- -
tain in the United States Army ;
Medical Corps from 1942 to 1946.
James Z. Zolli. At the untimely
age of 47, James Zeno Zolli, MD,
died on July 8, 1990. Dr. Zolli was
born in New York City on June 19,
1943, earning his medical degree
from State University of New York
Downstate Medical Center, Brook-
lyn, in 1970; his New York medical
license in 1973; and his New Jersey
medical license the following year.
Dr. Zolli served his internship and
residency at State University
Kings County Hospital Center,
Brooklyn. An ophthalmologist, Dr.
Zolli practiced in Elizabeth, New-
ark, and Springfield and was af-
filiated with Newark Eye and Ear
Infirmary; St. Elizabeth Hospital,
Elizabeth; St. James Hospital,
Newark; and Alexian Brothers
Hospital, Elizabeth. Dr. Zolli was
a member of our Union County
component. He also was a fellow of
the American Academy of Oph-
thalmology and Otolaryngology,
and of the American College of
Surgeons. Dr. Zolli was an assis-
tant clinical professor at the Uni-
versity of Medicine and Dentistry
of New Jersey, Newark.
834
NEW JERSEY MEDICINE
WMWIlIWUllOWIHQji
EDITORIAL CRITERIA
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
tent of each issue appears as scien-
tific articles, based on research,
original concepts relative to
epidemiology of disease, and treat-
ment methodology; case reports;
review articles; clinical notes; and
special articles, which include
evaluations, policy and position
papers, and reviews of nonscien-
tific subjects. Other topics include
commentary (critical narration);
medical history; therapeutic drug
information; pediatric briefs;
nutrition update; and opinions.
Editorials are prepared by the edi-
tor and by guest contributors on
timely and relevant subjects. The
Doctors’ Notebook section con-
tains organizational, infor-
mational, and administrative
items from MSNJ and from the
community. Letters to the editor
and book reviews are welcome and
will be published as space permits.
The principal aim in the prep-
aration of a contribution should be
relevant to diagnosis and treat-
ment and to education of patients
and professionals. Preference will
be given to professional authors
from New Jersey and to out-of-
state lecturers who submit a suit-
able manuscript based on a pre-
sentation made to an audience in
New Jersey.
Assignment of Copyright. In
compliance with the Copyright Re-
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a separate statement accompany-
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label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
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subject or responsible person, must
be included with the photograph.
Material taken from other publi-
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source; written permission must be
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Generic names should be used
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name. Proprietary names of de-
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References should not exceed 35
citations except in review articles,
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1. Goldwyn RM: Subcutaneous
mastectomy. NJ MED 74:1050-
1052, 1977.
2. Dixon WJ, Massey FJ: In-
troduction to Statistical Analysis.
New York, NY, McGraw-Hill,
1969, pp. 42-48.
Publication Policy. Receipt of
each manuscript will be acknowl-
edged; the paper will be referred to
the Editorial Board. The final de-
cision is reserved for the editor. No
direct contact beween the re-
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CINE, MSNJ, 2 Princess Road,
Lawrenceville, NJ 08648.
VOL. 87— NUMBER 10 OCTOBER 1990
835
YOU’RE PAYING
WHAT THE
GOVERNMENT
WON’T.
« . u^L
*0r
Many people blame doctors for the high
cost of health care. The truth is, physi-
cians' fees account for only 20% of all
health care costs.
So why is health insurance coverage
fast becoming a luxury for so many
Americans today? A major reason is cost
shifting. The federal government’s refusal
to shoulder its share of the cost means
the private sector— you and your employ-
er-are left carrying more of the burden.
The grouing cost of
uncompensated care
Cost shifting has had a particularly
devastating effect in New Jersey, which
is one of only three states to have an
Uncompensated Care Fund
(UCF). Begun in 1980 to
cover the cost of hospital ( not
physician )
care for the
indigent unin
sured, the UCF
has grown from
$80 million to
*
nearly $700 million today. The reason is
cost shifting.
Medicare won't pay
The UCF is funded from a surcharge
all private insurers must pay. But the
federal government's Medicare program
refuses to pay this surcharge. This
increases the amount all other iasurers
must pay, and higher premiums are the
result.
Medicare also refuses to reimburse
hospitals at the same rate as private
iasurers for the cost of patient care.
Again, the UCF is tapped to make up the
difference, which is expected to ap-
proach $400 million this year.
What you can do
The growing cost of uncompensated
care is just one of many reasons for our
state’s current health care cost crisis.
Through this series of articles, we hope
to familiarize you with more of them
and show what you can do to keep the
cost of quality care within the reach of
ail New Jersey’s residents.
Your County Medical Society and
i The Medical Society
of New Jersey
2 Princess Road • Lawrenceville, NJ 08648
Free reprints of this article and others in the series are
mailable from the Medical Society of New Jersey
836
NEW JERSEY MEDICINE
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS: 1988
As a result of AMA action and physician opposition, over
50,000 comments were received by the Federal Health Care
Financing Administration (HCFA) regarding the proposed
regulations on physician office laboratories. HCFA must
evaluate and respond to the comments and, in addition, must
perform a regulatory impact study before adopting the onerous
proposal. The AMA expects significant changes will be made
before final action is taken.
MEDICARE TO PAY ASSISTING SURGEONS
Through a series of negotiations between Dr. Ricci
(Pennsylvania Blue Shield) and Dr. Samson (MSNJ-American
College of Surgeons) , most issues regarding reimbursement for
assisting surgeons have been resolved. The PBS format is
compatible with the State Board of Medical Examiners with the
exception of a few hernia procedures still being reviewed.
1991 MALPRACTICE RATES — MIIENJ
The Medical Inter-Insurance Exchange of New Jersey (MIIENJ)
has announced its 1991 malpractice rates. Classes J
(gynecology and general surgery) ; K (plastic, cardiac,
thoracic, and vascular surgery) ; and N (orthopedics) will
enjoy a 9.67 percent decrease. All other classes will remain
at the 1990 levels. Additionally, the Board of Governors has
suspended the subordinated loan requirement for all new
insureds and has petitioned the insurance commissioner for
permission to begin redeeming outstanding subordinated loans.
The commissioner has not yet acted on that request. The 1991
rates, to be used for renewals in January, will be effective
November 1, 1990, for new business.
GOVERNOR'S COMMISSION FILES ITS REPORT
The Governor's Commission on Health Care Costs filed a
sweeping report with the governor and the Legislature calling
for a total revision of the health care delivery and
reimbursement system in New Jersey. In most instances, the
details necessary to implement the concepts presented are not
given. A serious number of practical and constitutional
questions are presented by the speculation caused by that
omission. The Commission did not give substantial weight to
practitioner and industry comments. The governor and the
Legislature will begin consideration of legislative and
regulatory proposals. MSNJ is prepared fully to address all
concerns and to represent patient and physician interests in
what will become a dramatic and probably heated process.
LITIGATION: MALPRACTICE SURCHARGE AND NO-FAULT
The medical malpractice surcharge suit was argued by MSNJ
special counsel Herbert Stern before the appellate division
on September 17, 1990; a decision is expected by the end of
November 1990. The automobile insurance litigation continues
through a procedural maze with the temporary restraining
order still in effect. MSNJ is represented by Robert Conroy,
of the firm of Kern, Augustine, Conroy & Isele.
MSNJ
NEWSLETTER
CALL FOR PAPERS: NEW JERSEY MEDICINE invites interested persons to submit articles
SPECIAL ISSUE for a special issue on Computers and Medicine to be published in spring
ON COMPUTERS 1991. Under the guest editorship of Richard M. Ball, MD, this special
issue will cover a variety of topics directed toward computer use by the
physician. Specific topics for articles might include: using on-line medi-
cal databases; getting physicians to use computers; subscribing to com-
puter journal information lines; drug interaction programs; coding soft-
ware; radiologic imaging; computer-assisted learning and testing; com-
puter-stored medical records; doctors as programmers; and personal
experiences with office business computer systems. Please send your
inquiries or manuscripts to Richard M. Ball, MD, 1907 Park Avenue,
South Plainfield, NJ 07080.
Under a new regulation, N.J.A.C. 8:57-3.2, physicians attending any
person who is ill or diagnosed with any of the diseases or poisonings on
the following list must report the case within 30 days to the New Jersey
State Department of Health: asbestosis; silicosis; pneumoconiosis, other
or unspecified; occupational asthma; extrinsic allergic alveolitis; and
lead poisoning, adult (blood lead > 25 micrograms per deciliter; urine
lead > 80 micrograms per liter). The required case report should include
the following information on the patient: diagnosis, date of onset of
illness, name, birthdate, sex, home address, telephone number, and
name and address of employer at the time ot exposure.
REGULATION FOR
OCCUPATIONAL
DISEASES AND
POISONINGS
Reports may be submitted by telephone (609/984-1863) or mailed to
“SENSOR” Occupational Health Service, New Jersey State Depart-
ment of Health, CN 360, Trenton, New Jersey 08625-0360. Reporting
forms and a copy of the new regulation may be obtained from this
address.
Reports will be included in the New Jersey State Department of Health’s
surveillance system for occupational diseases and poisonings. The goal
of this surveillance system is prevention through case identification and
followup at worksites where workers may continue to be exposed to the
hazards that caused disease in the reported case.
MEDICARE PAYMENT The AMA firmly opposes the 14-day hold in payment by Medicare
HOLD IS UNFAIR carriers and told the Health Care Financing Administration (HCFA)
that this delay is unfair and imposes hardships on physicians and pa-
tients. The federal government benefits from this lag in payment at the
expense of Medicare patients, the AMA said. This legislatively man-
dated hold on payment attempts to balance the budget on the backs
of those who are supposed to be protected by Medicare. Carriers should
pay claims promptly and efficiently, the AMA told HCFA.
NATIONAL
PRACTITIONER
DATA BANK
James S. Todd, MD, AMA executive vice-president, met with Represen-
tative Ron Wyden (D-OR) to resolve some of the tough problems in-
volved in implementing the National Practitioner Data Bank. The AMA
raised a number of concerns about data bank operations that could
adversely affect physicians: inconsistent reporting of medical liability
VOL. 87— NUMBER 11 NOVEMBER 1990
851
MSN J NEWSLETTER
determinations; inappropriate data retention; and inadequate confiden-
tiality protections. A new AMA booklet explains the Data Bank’s im-
plications for physicians. The National Practitioner Data Bank, Infor-
mation for Physicians describes the Data Bank and clarifies reporting
and querying requirements. To order, call 1/800/262-3211; free to AMA
members.
ANTI-HASSLE BILL
The AMA-sponsored Medicare “anti-hassle” reform bill, HR-4475, now
has 169 cosponsors in the U.S. House of Representatives. The bill con-
tains five major reforms that would reduce the hassles you face from
third-party interference in your practice. Call or write your Con-
gressional representatives and urge them to support HR-4475 in the
House and S-2591 in the Senate. Call 202/224-3121 and ask for your
senator or representative by name.
LABORATORY
REGULATIONS
Proposed cytopathology regulations on physician office laboratories are
an unprecedented intrusion into the practice of medicine, the AMA told
the Health Care Financing Administration (HCFA). The AMA objects
to including physicians in the proficiency testing requirements of these i
regulations. Not only could these rules deny a physician the right to
practice medicine if the physician fails to pass a cytology proficiency
test, the rules also may violate state regulation of medical licensure, the
AMA told HCFA. Additionally, the rules will lead to inspection and
proficiency testing problems. The AMA cautioned that these regulations ;
are bad for patients too. In rural areas, small laboratories may have to
close. And if the new rules are not modified, the availability of many
services could be severely jeopardized, the AMA asserted.
AMA SUPPORTS
TORT REFORM
The AMA favors many of the medical liability reforms proposed by the
federal government in “Report on Health Care for All Americans.” Fed-
eral tort reform must be part of any viable plan to expand access to
quality care, stated the AMA. In a recent letter to Congress, the AMA
spelled out the tort reforms it wants for fair disposition of liability
claims: periodic payment of damages; a $250,000 cap on noneconomic
damages; offset of other sources of payment for damages; a sliding scale
of attorney contingent fees; and a statute of limitations for minors of
no more than six years from birth. The AMA also wants federal funding
of state demonstrations to find alternative ways of resolving disputes.
DESIGNATED
SPECIALTY
REIMBURSEMENT
The AMA is demanding that the new “designated specialty” Medicare
payment limitations be recalled. Before implementing these limits, the
Health Care Financing Administration (HCFA) should have given phy-
sicians proper notice and also should have published the criteria used
in choosing the so-called “high volume” services subject to these limits.
A comment period also should have been allowed. The AMA told HCFA
that Medicare payment limits for “over-valued” services might affect
some of the same physicians hit with designated specialty payment cuts.
Some physicians could face two devastating payment cuts at once and
might be discouraged from treating Medicare patients, the AMA said.
PHYSICIAN SUES
A New Jersey physician, Bernard E. Benson, MD, filed a legal malprac-
ATTORNEY tice suit against an attorney who allegedly failed to properly represent
him in a malpractice suit. A trial court in Philadelphia ruled the doctor
had no grounds to sue Philadelphia attorney James Griffith. The doctor
filed an appeal and the AMA filed a friend of the court brief on his
behalf. A state appellate court reinstated the case and declared that the
doctor is entitled to have his case heard. Dr. Benson said he suffered
more than $1 million in damages because Griffith failed to have court
records sealed after settling a malpractice suit against Dr. Benson.
852
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
ALLIED HEALTH EDUCATION
The MSNJ House of Delegates called for recognition and support for all levels of allied health
education at the 1990 Annual Meeting, and the Task Force on the Shortage of Nurses and
Technical Personnel submitted a proposal to the Board of Trustees. Part of the Task Force
response was to make a series of recommendations for the edification and guidance of physicians.
The Board of Trustees approved the following recommendations on September 16, 1990:
In support of allied health education
RECOMMENDATION
That members of the Medical Society of New Jersey be urged:
(a) To distribute and to make available in their offices, hospitals, and clinics, pamphlets
and brochures concerning careers and educational programs in the allied health professions.
(Such pamphlets are available from the New Jersey Hospital Association Nursing and Allied
Health Resource Center.)
(b) To make informed educational referrals for students, patients, and others where ap-
propriate toward careers in the allied health professions.
(c) To participate in and to support the allied health educational programs in their area.
(d) To support legislation for allied health programs in New Jersey.
In support of job retention and recruitment
RECOMMENDATION
That members of the Medical Society of New Jersey be urged:
(a) To support appropriate salary levels for allied health professionals.
(b) To include the allied health professional in an appropriate level of discussion concerning
patients and procedures.
(c) To respect the allied health professional as an essential and endangered member of the
health care team.
MALPRACTICE REFORM Senator Orrin Hatch (R-UT) has introduced a bill that could reduce the
BILL INTRODUCED number of medical malpractice lawsuits and amounts awarded from
such suits. Hatch’s bill would provide funding for states to establish
systems of binding arbitration that would limit noneconomic damages
to $250,000 and require states to review and resolve patients’ claims
within six months. Funding of $5 million would be provided in 1991 with
up to $200 million in 1992 and $75 million in 1993 being provided. The
bill has received broad-based support from the health care industry,
including the American Hospital Association, the American Medical
Association, and the Federation of American Health Systems.
MEDICARE HMO California Medical Review Inc., the country’s largest peer review or-
QUALITY PROBLEMS ganizati°n> has found that Medicare HMOs had the highest percentage
of confirmed quality problems of any setting reviewed during the year
that ended March 31, 1990. Medicare HMOs experienced confirmed
quality problems in 7.94 percent of the samples reviewed. Review of
intervening care related to readmissions to hospitals from nursing homes
or home health agencies, review of acute care hospitals, and review of
ambulatory surgery were the three areas identified as the highest quality
review problems.
The Health Care Financing Administration has proposed rules to charge
most clinical laboratories $261 every two years for Medicare and Medi-
caid certification. These fees are expected to impact 312,000 hospital-
based, independent, and physician office laboratories; these laboratories
will be classified into ten categories based on the number of specialties
and the volume of tests performed. In addition to the basic $261 fee,
LABORATORY USER
FEES
/OL. 87— NUMBER 11 NOVEMBER 1990
853
MSNJ NEWSLETTER
laboratories inspected by state surveyors would pay $840 to $2,870 and
laboratories needing followup visits or complaint investigations will pay
an additional $525 to $1,120. These fees were mandated by a 1988 federal
law on laboratory inspections and are designed to cover costs incurred
in performing certification-related activities.
FINANCIALLY
DISTRESSED
HOSPITALS
A study by Health Care Investment Analysts Inc. has found that one
of every ten U.S. hospitals has serious financial problems caused by
significant declines in utilization of cash flow. The study identified 538
distressed hospitals and estimated that half of these facilities will be
closed within four years. Sixty-five percent of the distressed hospitals
are located in urban areas with approximatley 50 percent having less
than 100 beds and 38 percent having between 100 and 249 beds. A
distressed hospital is defined as a facility experiencing substantial
adverse changes in utilization, payor mix, profitability, capital structure,
and/or liquidity.
STUDY OF THE
UNINSURED
According to a study performed by the Employee Benefit Research
Group, over 33 million nonelderly Americans who are not eligible for
Medicare or Medicaid did not have private health insurance coverage
in 1988. Uninsured rates vary widely by state, ranging from a iow of 8.3
percent in Michigan to 28.1 percent in New Mexico. States with the
highest uninsured rates included Alaska, Arizona, Arkansas, Florida,
California, Louisiana, Mississippi, Nevada, New Mexico, Oklahoma,
and Texas. Over half of the uninsured were employed. The 18.5 million
uninsured workers represent 15 percent of the U.S. workforce.
RETAILERS AND
RESTAURATEURS
OPPOSE HEALTH
INSURANCE TAX
Restaurant owners and retailers have formed a coalition, known as Help
Establish Affordable Health Care Laws (HEAL), to oppose a proposed
payroll tax to fund mandatory health insurance. The payroll tax
proposal, which is supported by the AFL-CIO, would provide health
insurance for the estimated one million New Jersey employees without
health insurance. In a letter to Governor Jim Florio, the members of the
Governor’s Commission on Health Care Costs, and the Legislature,
HEAL said that it was “seeking health care reforms that would provide
affordable, accessible health care coverage to state residents without
imposing mandatory health insurance or taxes that could have an
adverse economic impact on New Jersey’s business community as well
as individuals.” HEAL is comprised of the New Jersey Chamber of
Commerce, the New Jersey Food Council, the New Jersey Restaurant
Association, and the Health Insurance Association of New Jersey. The
AFL-CIO supports the payroll tax because, under the current system,
employers that provide health insurance coverage are forced to cover the
cost of health care associated with employees that are not covered by
health insurance.
OREGON HEALTH CARE
RATIONING PLAN
One of the designers of Oregon’s health care rationing plan is calling
for the state to drop the plan. John Golenski, president of Bioethics
Consultation Group, argued that the state’s decision to exempt the
elderly compromises the rationing plan and places the burden on poor
women and children. According to Golenski, the state legislature ex-
empted geriatric health care from the rationing plan due to concerns of
a political backlash from the elderly.
MSNJ PUBLIC The Medical Society of New Jersey public service television release,
RELATIONS AWARD "The View of Earth From Space is Indescribably Beautiful,” won a
Meritorious Achievement citation at the prestigious Berny Awards.
FINI “No man can sincerely try to help another without helping himself.
854
NEW JERSEY MEDICINE
PROFESSIONAL
LIABILITY
COURT CLARIFIES ROLE
OF DEFENSE COUNSEL
IN FILMING
A “day in the life” film occasionally is used by plaintiff s counsel to
chronicle every detail of the life of a plaintiff from morning to night,
and can serve as a powerful tool in swaying jury sympathies and gar-
nering larger awards.
The minor plaintiff filed a suit alleging that the defendants were negli-
gent in providing medical service. The defendants obtained an order in
the trial court allowing their presence during the filming of the “day
in the life” film of the minor plaintiff.
The plaintiffs counsel refused to comply with the order, and the trial
court held one of the plaintiff s counsel in contempt and imposed a $100
fine. “Day in the life” films were first approved by the Illinois courts
in 1986; however, the issue of the presence of the defendants’ counsel
never had been addressed.
In addition to reversing the finding of contempt and the fine, the ap-
pellate court held that the film could be prepared without the presence
of any of the defendants’ representatives. However, the court also took
steps to ensure that material potentially favoring the defense case be
preserved and made accessible to the defense.
In this case, the plaintiff was required to preserve all of the film, whether
included or not in the final version. The defendants then were entitled
to view all of the film prior to trial, to take the discovery deposition of
any witnesses who would authenticate the film, and to use any film taken
by, but not used by, the plaintiff— assuming such film was deemed
admissible.
Likewise, the court held that the defendants had to disclose the existence
of any film the defendants intended to use to refute the plaintiffs
disability. In such a situation, the plaintiff would be entitled to view
all of the film, take discovery depositions of authenticating witnesses,
and use film taken but not utilized by the defendants.
A further appeal was filed, and the case is now pending before the Illinois
Supreme Court. (Reprinted from Professional Liability Update, Ameri-
can Medical Association, May/June 1990.)
An Illinois Appellate Court reversed an order requiring that defendants’
counsel be present for the filming of the plaintiffs “day in the life” film.
It also reversed an order holding the plaintiff s counsel in contempt and
fining her for refusing to comply with the lower court’s order. However,
the court also made several rulings to protect the authenticity of such
a film and to give defense attorneys access to recorded materials before
a trial and use of certain materials during a trial. It also established
rights that plaintiffs have to materials obtained by the defendants.
NEW TRIAL ON
ISSUE OF DAMAGES
A physician was entitled to a new trial on the issue of allocation of
damages in an action awarding a patient and his wife $806,330.02 in
damages for negligent treatment of an arm fracture, a New Jersey ap-
VOL. 87— NUMBER 11 NOVEMBER 1990
857
PROFESSIONAL LIABILITY
pellate court ruled. In a second trial on the issue of damages, a court
awarded the patient $436,000 and his wife $120,000 which when added
to prejudgment interest resulted in an $806,330.02 judgment. The jury
found that the physician was negligent in performing an open reduction
of a comminuted fracture of the distal humerus of the patient’s left arm
suffered in an automobile accident.
On appeal, the appellate court said that a second retrial was necessary.
The total dollar amount of damages already was determined and did
not need to be determined again. However, the physician should be given
an opportunity to prove what portion of the patient’s total damages for
lost wages, medical expenses, general damages, and loss of consortium
was not attributable to his malpractice and what part of the damages
would be attributable to the probable consequence of a properly treated
fracture of similar gravity. (Reprinted with permission from the The
Citation, American Medical Association, Volume 61, July 1, 1990.)
FULL DISCLOSURE
STATEMENTS WITH SET
PATIENT BENEFITS FOR
ADVERSE OUTCOMES
An innovative new program to defuse suits against surgical specialists
arising from unanticipated adverse outcomes will be marketed soon in
six states. “Eighty-five to 90 percent of suits against surgeons are
brought because of failed patient expectations,” says DeWayne L. Hull,
MD, Fort Wayne, Indiana, plastic surgeon and program creator. “Our
Physicians Risk Control program is designed to fully disclose some of
the maloccurrences that may be associated with a given procedure.
There are no surprises if there is some adverse outcome.”
Disclosure programs are fairly common, but what makes the Physicians
Risk Control (PRC) program different is that it pays a modest benefit,
based on a set schedule for various procedures, to a patient who ex-
periences an adverse outcome. For example, if pregnancy results, despite I
a laparoscopic tubal ligation procedure, the patient receives a monetary
benefit of $2,500. A failed vasectomy results in payment of $1,000 to a
patient. These payments are made even when no negligence was involved
in performance of the procedure.
“We don’t get into negligence issues,” says Dr. Hull. “The program gives
the patient an economic benefit if something untoward does take place.
In the current world, a doctor would be fearful that any offer he might
make to compensate in some way for an adverse outcome could be
construed as an admission of negligence by a plaintiff attorney. However,
in our program the disclosure statement, including a description of the
specified benefit if something goes wrong, is mutually completed by
doctor and patient before care is given.”
Because PRC is a quasi-insurance product, it must be underwritten by
a qualified insurer who will accept and hold participating physicians’
premiums and pay out benefits as required. Dr. Hull has entered into
a joint venture with Rollins Burdick Hunter, Chicago. Virginia Surety,
a subsidiary of the Chicago-based Aon Corporation, will provide the
underwriting. Dr. Hull, working with a number of advisors including
former AMA President Dr. Ed Annis, is responsible for the development
of the disclosure statements and the marketing of the program na-
tionwide.
Here is how the program works: A surgical specialist would review the
list of 66 disclosure statements in seven specialty areas available through
PRC. For each procedure the physician selects procedures that he be-
lieves are high risk for triggering suits and then calculates a premium.
He does this by estimating the number of times each year he performs
that particular procedure. Using PRC’s actuarially computed tables of
858
NEW JERSEY MEDICINE
PROFESSIONAL LIABILITY
the per procedure cost to insure a benefit in the event of an adverse
outcome, that range from about $37 to $45 per procedure, he multiplies
the number of times he does the procedure by the per procedure cost.
If he does 60 procedures for which the per procedure fee is $40, then
his annual premium is $2,400. He can pay it in one lump sum or he
can pay 20 percent up front and finance the rest. He also can withdraw
from the program along the way and his premium will be refunded.
In effect, the patient pays the procedural fee, that some might equate
with “trip insurance,” because it is added to the total bill. However,
it often can be recouped from an insurer. “There is a specific CPT code
that permits billing for explanations and disclosure,” says Dr. Hull.
An enrolled surgical specialist receives disclosure brochures for the
procedure(s) he has designated. Each brochure has been developed by
surgeons in the given specialties including obstetrics/gynecology, and
general, plastic, podiatric, orthopedic, urological, and cardiovascular
surgery. Each brochure describes the given procedure, outlines alterna-
tives to it, and lists possible maloccurrences. The patient signs a state-
ment saying, “I have been advised of the risks and alternatives of (the
procedure) and the associated anesthesia.” Also, the patient signs, “I
am aware that the practice of medicine is not 100 percent perfect in
preventing maloccurrences and I understand my doctor cannot guaran-
tee to me that I will not have a maloccurrence with this procedure.”
The signed disclosure statement does not replace the informed consent
process. Each doctor should continue to obtain informed consent in his
own manner, using his own documents and methods.
What the signed disclosure statement does do is discourage any suits
alleging failure to achieve informed consent in the event of a bad out-
come. The fact that disclosure is documented with the patient’s own
signature and that a predetermined benefit is paid for a poor or unex-
pected outcome is a “powerful deterrent to litigation.”
“Even if a suit does arise, the defendant doctor’s position is considerably
strengthened by his ability to produce the signed disclosure statement,”
says Dr. Hull.
However, the Physicians Risk Control program is no substitute for pro-
fessional liability insurance, warns Dr. Hull, even though a physician
need not carry it to participate in PRC. “What we do anticipate is that
after a year or so of experience with the program, a doctor can approach
his insurer and request a discount on his premium because of his partici-
pation with us,” he suggests. “This is not a program for every doctor,”
says Dr. Hull. To participate in PRC, a physician must be board certified
or board eligible or have limited the practice to a particular surgical
specialty for at least three years.
The program will be marketed immediately in Illinois, Michigan, Ohio,
Florida, New York, and Virginia, using printed materials and a 12-
minute audiocassette. Dr. Hull says plans are to move as quickly as
possible to obtain insurance department approvals in other areas.
Surgical specialists for whom specific disclosure brochures already have
been prepared will be targeted first, either individually or via some of
the specialty societies that already have expressed interest in the PRC
program. As time goes on, new brochures for other procedures will be
developed. “This will be a physician-sensitive program,” Dr. Hull says.
(Reprinted with permission from the Medical Liabdity Monitor, Win-
netka, IL 60093. July 24, 1990, Volume 15, Number 7.)
VOL. 87— NUMBER 11 NOVEMBER 1990
859
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YOCON
YOHIMBINE HCI
Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renefgic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both
Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug . Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone
Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.
Indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac
Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications
Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.
Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.1'? Also dizziness,
headache, skin flushing reported when used orally.13
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence.1'3'4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon^ 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000's NDC
53159-ooMo.
References:
1. A. Morales et al. . New England Journal of Medi-
cine: 1221. Novembers, 1981.
2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed. , p. 176-188.
McMillan December Rev. 1/85.
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales et al. , The Journal of Urology 128:
45-47, 1982.
Rev. 1/85
AVAILABLE AT PHARMACIES NATIONWIDE
PALISADES
PHARMACEUTICALS, INC.
219 County Road
Tenafly, New Jersey 07670
(201) 569-8502
1-800-237-9083
860
NEW JERSEY MEDICINE
EDITOR’S
DESK
MEDICAL Medical research is a relatively new development in the long history of
RESEARCH medicine, with basic research attempting to understand underlying
mechanisms of life and disease, and applied research using the basics
in clinical settings or in the study of the delivery of care. The first large-
scale medical research was carried out in German universities in the
1800s, establishing the firm commitment to simultaneous teaching and
research that characterizes today’s universities.
But nonuniversity research also flourished in the 19th century, supported
by public and private funds. The initial showcase, the Pasteur Institute,
was followed by similar foundations in Germany, Russia, England, and
Japan. In the United States, the Woods Hole Marine Biological Labora-
tory and the Wistar Institute in Philadelphia were among the first of
these independent research institutions.
The infusion of large amounts of private welfare into the field created
the Rockefeller Institute for Medical Research in 1901 and the Carnegie
Institution of Washington, DC, in 1902. Physicians also used their pri-
vate resources as stimuli for the establishment of various foundations.
Note the efforts of Dr. Edward L. Trudeau and Doctors Charles and
William Mayo and the spate of other high-minded similar organizations
that followed.
Governmental involvement, of marginal value initially, accelerated in
the United States in the 1930s. The Hygienic Laboratory became the
National Institutes of Health (NIH) in 1930. The National Cancer In-
stitute was spawned in 1937. No longer do these agencies merely stimu-
late the monetary flow from private individuals. No longer do they
merely award grants-in-aid and monitor their effects. They also do much
independent research, in both basic and applied modes. So, in today’s
world we see all these forces competing — the universities, the indepen-
dent foundations, and the government.
We are indebted to Dr. Lippman and his associates for this sampling
of research performed in New Jersey. As is true of medical education,
medical research is a prominent activity in the state, not dependent on
or inferior to similar activities in neighboring states. Medical research
in New Jersey has come of age.
But our delight in the progress noted in New Jersey research is not
unalloyed. In today’s world of increasing technology and sophistication
come increasing caveats, relating to conflicts of interest and to accuracy
of reporting.
Pharmaceutical and other manufacturers influence clinical research to
the point of scandal. The favorable reporting of a new medication can
mean millions in profit to the drug company. Failure of an investigator
to disclose financial ties to the supplier, regardless of degree, is not only
unethical but, at times, may be fraudulent. A requirement that all
authors disclose their potential financial conflicts of interest is both
reasonable and prudent.
VOL. 87— NUMBER 11 NOVEMBER 1990
861
EDITOR’S DESK
We should be equally concerned about the scientific validity of the
articles published. It should not be necessary for the editorial staff to
review all of the raw data, as had been proposed by JAMA, and about
which we previously commented, but the erudite reader should under-
stand that a high percentage of scientific articles do not meet reasonable
criteria for validity. Even the authors of many of these flawed studies
fail to realize their errors; these are “honest” mistakes. We cannot read
only abstracts or conclusions, data need to be examined in full. Some
basic knowledge of statistics can be helpful to the reader and should be
mandatory for the authors. And it could help the media to achieve some
semblance of truth.
It will not be easy to improve the validity of published research. Much
statistical analysis will be needed. It should be easier to insure that
financed researchers have clean skirts, unsoiled by the blandishments
of industry. The expected nomination of Dr. Bernadine Healy of the
Cleveland Clinic to head NIH may help, although it may prove interest-
ing to see how she handles grants earmarked for that Ohio institution,
the target of many previous NIH grants and the employer of her phy-
sician-husband. □
“The great tragedy of Science — the slaying of a beautiful
hypothesis by an ugly fact.”
Thomas Henry Huxley,
Biogenesis and Abiogenesis (1870)
862
NEW JERSEY MEDICINE
BOOK
REVIEWS
CLINICAL UROGRAPHY:
AN ATLAS AND
TEXTBOOK OF
UROLOGICAL IMAGING
Howard, M. Pollack, MD (ed). Philadelphia, PA, W.B. Saunders, 1990.
This extensive, easy-to-read, three-volume text covers the discipline of
genitourinary radiology. The book is divided into sections: a general
discussion of the field; various imaging procedures (from plain films to
MRI and lymphography); specific disease entities such as congenital
disorders, neoplasms, and vascular diseases; indepth analysis of the
diseases of the adrenal gland; abnormalities of the retroperitoneum and
other miscellaneous disorders; and reviews of renal transplantation and
interventional radiology.
The authors are acknowledged leaders in the field, and display a writing
ability to match. The images are first rate. This book is one of the most
exhaustive treatments of the subject with up-to-date approaches to the
diagnosis of genitourinary system diseases. □ Neil B. Horner, MD
CURRENT OPERATIVE E. Douglas Whitehead, MD (ed). Philadelphia, PA, J.B. Lippincott
UROLOGY. 1990 Company, 1990. This volume is an apt successor to the unique texts
previously published in this series. It follows the format of an annual
edition, published after a previously successful encyclopedic text.
In the first two editions of Current Operative Urology, the expert in each
area selected a seminal article to serve as the basis of the evolving
understanding of a particular operative approach. An annotated bibli-
ography was provided. The expert, in his commentary, analyzed the
operative approach from the standpoint of historical perspective, allow-
ing the student to gain insight into the problems inherent in the oper-
ation, and how solutions were formulated. The emphasis on under-
standing the evolution in thinking is unique in surgical texts, and
provides a better understanding of what has come to be the current
“state of the art.”
Because his commentary is less formalistic when compared to standard
texts, the expert also was able to personalize the discussion, providing
a better understanding of the actual operative approach. Following the
commentary is an overview, in which another expert discusses the same
problem. This approach, a roundtable discussion instead of a pedantic
summary, is an effective teaching method.
In this current volume, Whitehead has maintained the successful format
of the previous volumes, but has narrowed the focus because the current
explosion of knowledge in medicine demands more rapid digestion and
dissemination. Whitehead believes that a voluminous tome is too long
in production, and frequently too expensive. Where a shotgun previously
was effective, a rifle now is needed.
The text covers ten sections: renal transplantation, surgery for incon-
tinence, continent diversion, augmentation enterocystoplasty,
carcinoma of the testis, surgery for male infertility, reflux, posterior
urethral valves, postnatal obstructive emergencies, and laser surgery.
Whitehead has been eminently successful in having these selected areas
VOL. 87— NUMBER 11 NOVEMBER 1990
BOOK REVIEWS
expertly and comprehensively developed. This text should stand the test
of time, and is strongly recommended for inclusion in the library of every
urological surgeon. □ John H. Lifland, MD
DIAGNOSTIC Bruce Benjamin. W.B. Saunders Company, Philadelphia, PA, 1990. This
LARYNGOLOGY book fulfills its name by giving a state-of-the-art review of the procedures
for diagnosing laryngeal pathology. The text is very clear in its descrip-
tions of the modalities avaifable for performing laryngeal diagnostic
procedures. The strongest point in this book is the second part that has
photographs of the various laryngeal pathologies. Careful study of these
pictures will give the reader a very complete picture of the diseases
present in the larynx. However, the main drawback of the procedures
mentioned in this book is that the greater majority of the
otolaryngologists would not be in a position to have the necessary equip-
ment to perform the procedures as described. There are very few places
in the world that have all the equipment to do state-of-the-art exami-
nations. Therefore, it can be somewhat frustrating for the average
otolaryngologist to read this book and realize it is not in the realm of
his capability to perform the mentioned procedures. Yet, it is without
reserve that I recommend this book to otolaryngologists and to anyone
else interested in laryngeal pathology, as the text gives a complete
picture of state-of-the-art diagnostic procedures. □ Harold Arlen, MD
Dale R. Dunnihoo, MD. J.B. Lippincott Company, Philadelphia, PA,
1990. Doctor Dunnihoo of the Louisiana State Medical School has per- ,
formed a tremendous feat by putting together an enormous amount of
material covering every aspect of the office and hospital practice of
obstetrics and gynecology. Fundamentals serves as a textbook for medi-
cal students as well as a practical guide for family physicians and
internists. So exhaustive and thorough is the information that physicians
preparing for certification or recertification might select this book to
advantage. The material is well organized and clearly presented with
a somewhat unusual system of three typographical variations so that the
reader can easily differentiate more important facts from the less impor-
tant. There is only one problem with this book — minimal discussion of
potentially controversial aspects of new information unsupported by
references. Most clinicians read recently published textbooks, expecting
that the authors have sifted through the mountains of publications
arriving almost daily, have separated fact from fiction, and have pre-
sented authenticated valuable new information. All too frequently most
clinicians have learned that sometimes new information has been proved
false and that new procedures and treatments subsequently have been
proved ineffective or even harmful. Although references can be selected
to substantiate almost anything, references do serve to indicate that
recent publications by recognized and respected authorities have been
read. This book is recommended with reservation. □ Jerome Abrams,
MD, MPH
Robert B. Lufkin, MD, and William N. Hanafee, MD. New York, NY,
Raven Press, 1989. This core text provides a handy guide to the normal
anatomy of the base of the skull and neck. The book is arranged in four
parts: neck, oropharynx, nasopharynx, and skull base. Each section then
is subdivided into axial, sagital, and coronal planes. Unfortunately, only
T-l weighted images are included. T-2 and contrast-enhanced MRI
images are not addressed. The overall quality of the images rates fairly
well with the various anatomical areas clearly labeled. The book delivers
what its title promises: a pocket atlas that best serves the radiologist
or clinician requiring a quick reference. □ Neil B. Horner, MD
POCKET ATLAS OF HEAD
AND NECK MRI
ANATOMY
FUNDAMENTALS OF
GYNECOLOGY AND
OBSTETRICS
866
NEW JERSEY MEDICINE
SPECIAL ISSUE
Medical Research in
New Jersey
ALAN J. LIPPMAN, MD
New Jersey has a long and distinguished his-
tory of providing quality, up-to-date medi-
cal care for its residents. Nevertheless, for
certain high technology innovative treatments, New
Jersey patients consider medical care at centers in
New York or Philadelphia. Many New Jersey physi-
cians remain unaware or unconvinced, however, that
new technologies undergoing development in our
state may have immediate clinical relevance and
application, and may spare New Jersey residents the
need to seek treatments elsewhere for modern treat-
ments heretofore unavailable closer to home.
Often, as practicing physicians in New Jersey, we
may not be sufficiently aware of the existence of
such ongoing research nor the importance and im-
mediate relevance to our patients of some of the
newer treatment modalities being introduced in our
state. In addition, patients, through the media, are
becoming more educated consumers of health care.
They, in turn, wish to learn as soon as possible about
the latest and most innovative treatments. Phy-
sicians, hence, need to be informed.
In this special issue,
NEW JERSEY MEDI-
CINE focuses attention
on some of these matters
by considering certain
basic research areas and
the ways in which these
research efforts bear
Dr. Lippman is guest editor of
this special issue.
upon the current clinical practice of medicine.
The topics included in this issue are wide ranging,
covering a number of specialty areas; however, there
remain many more areas deserving of consideration.
Omission of certain subjects and of many other repu-
table and productive investigators from this particu-
lar issue should not be construed as discriminatory
nor imply “exclusivity.”
Ideas and articles for this issue were solicited from
physicians representing both the clinical and
academic arenas throughout the state. More than
125 letters of inquiry were sent to medical leaders
representing the entire spectrum of New Jersey
health care facilities including directors of research
at each of the medical schools, directors of research
or chairmen of institutional review boards at all
major New Jersey hospitals, presidents of the Medi-
cal Society of New Jersey, the Academy of Medicine
of New Jersey, and the various subspecialty societies
within the Academy, representatives of the various
state health care agencies, and medical directors of
all major pharmaceutical organizations in New Jer-
sey.
As a result of the initial survey, about 25 areas of
interest were identified; the 11 topics in this issue
represent a distillate of many that were suggested.
All interested investigators are invited to consider
NEW JERSEY MEDICINE as a vehicle for publish-
ing relevant clinical reports and disseminating re-
sults of clinical research that may have immediate
bearing on patient management. This will have the
effect of placing New Jersey in the forefront of “state
of the art” medical practice. B
VOL. 87— NUMBER 11 NOVEMBER 1990
871
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may make all the difference later.
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same way, the medical malpractice insurer you
choose now may make all the difference to your
professional and financial well-being in the years
ahead.
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company with a solid track record. A company
with years of experience providing professional
liability insurance for physicians, and a history of
successfully defending policyholders against mer-
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enough to design policies that meet your individ-
ual coverage needs. Our innovative Occurrence
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so service is prompt and professional. Plus, our
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Innovative Methods of
Cardiac Defibrillation
LAWRENCE J. GESSMAN, MD
Sudden death caused by fatal cardiac arrhythmias represents a major health
care problem in New Jersey. The use of a remote transtelephonic de-
fibrillator, a technique undergoing development, is an interesting new ap-
proach to provide prompt restoration of cardiac rhythm and function.
The American Heart Association estimates
that there are approximately 400,000 sudden
deaths per year in the United States
presumably due to ventricular tachycardia (VT) and
fibrillation (VF). Sudden death is the number one
public health problem in the United States. For-
tunately, we have the “cure” for sudden arrhythmic
death: early defibrilla-
tion. Unfortunately, a de-
fibrillator rarely is pres-
ent in time at the place of
Dr. Gessman is director of
electrophysiology, Deborah
Heart and Lung Center. Ad-
dress requests to Dr.
Gessman, Deborah Heart
and Lung Center, Browns
Mills, NJ 08015-1799.
occurrence of VT-VF, usually in the patient’s home
or other location outside of the hospital.
Despite advances in mobile rescue, fewer than 5
percent of all sudden death victims are successfully
resuscitated.1 Fewer persons still are appropriately
referred for electrophysiologic workup to prevent the
high recurrence rate of VT and VF, which has been
reported to be 30 percent in the first year after initial
successful resuscitation.2
This article will review advances in defibrillation
that should reduce the out-of-hospital mortality
from VT and VF. The article focuses on approaches
to outpatient defibrillation using telephone con-
trolled and automatic external defibrillators
(AEDs); improvements in automatic implanted de-
fibrillators; and a discussion of the elec-
trophysiologic workup and risk stratification for pa-
VOL. 87— NUMBER 11 NOVEMBER 1990
873
tients at risk of sudden death, including how to
choose patients for antiarrhythmic drug therapy,
internal automatic defibrillator therapy, and ex-
ternal telephone controlled defibrillation or AED
therapy.
EXPERIENCE WITH MOBILE RESCUE
Pantridge, in 1966, was first to use a mobile rescue
ambulance system to provide early defibrillation.
Since then, hundreds of thousands of VT-VF victims
have been successfully resuscitated by mobile rescue
paramedics. In a few, well-funded and well-publi-
cized systems, as many as 25 to 30 percent of all
sudden death victims are successfully resuscitated.3
However, nationwide less than 5 percent of all arrest
victims are resuscitated.
New Jersey statistics are closer to the national
average, and not improving. The last five-year ex-
perience from the Overlook Hospital Mobile In-
tensive Care Unit (MICU) (Table) shows the aver-
age resuscitation rate to be 6.2 percent, but the
MICU’s failure to improve out-of-hospital sudden
death survival odds over the last few years. Survival
is directly related to the time from patient collapse
to time of defibrillation. For example, patients with
implanted defibrillators experiencing sudden VT
and VF usually are defibrillated within 15 seconds
with almost 100 percent survival without need for
cardiopulmonary resuscitation. For VF patients re-
suscitated by mobile rescue, if CPR is started im-
mediately by a witness at time of collapse, and de-
fibrillation accomplished within one to three
minutes from collapse, then survival can be as high
as 30 to 45 percent.3 Even if CPR is started immedi-
ately, however, survival statistics fall dramatically
to less than 15 percent if defibrillation is not ac-
complished within ten minutes of patient collapse.
Recent advances in defibrillation technology have
the potential to reduce response time, and, there-
fore, increase survival dramatically. Two new in-
novative approaches to out-of-hospital external de-
fibrillation will be described.
TRANSTELEPHONIC DEFIBRILLATION
Drs. Gessman, White, and Raman, from Deborah
Heart and Lung Center, Browns Mills, invented and
tested a telephonic defibrillation system to enable
outpatient defibrillation to be administered by mini-
mally trained lay witnesses, including spouses of
high-risk patients, and volunteer ambulance workers
not currently certified to defibrillate.4
The telephone defibrillation (Medphone Corpora-
tion, Paramus, New Jersey) consists of a portable
attache case containing a standard 360 joule de-
fibrillator, a speakerphone, telephone electrogram
(ECG) telemetry circuits, self-adhesive ECG-
monitor defibrillation electrodes, and telephone con-
trol circuits that allow a remotely located physician
to operate the defibrillator by tone-code control (Fig-
ure 1). The telephone defibrillator patient unit auto-
matically dials a base station when opened (Figure
2). The base station is staffed by a coronary care unit
nurse or physician, who observes the telemetered
ECG, and assesses electrode contact by electrode
impedance telemetry (high impedance means poor
or no electrode contact), obtains history of un-
consciousness from the witness via the speaker-
phone, and charges the defibrillator to any one of
Table. Overlook Hospital Mobile ICU rescue data.'
Total Patients
Resuscitated in
Field
Total Initial
Saves (Patients
Admitted Alive
to Hospital)
Long-Term
Survivors
Year
No.
Percent
No.
Percent
1985
177
20
11
6
3.4
1986
153
31
20
12
7.8
1987
165
36
22
13
7.9
1988
156
34
22
12
7.7
1989
123
18
15
5
4.1
Total
‘Data from Dr. John Gregory
774
139
18
48
6.2
874
NEW JERSEY MEDICINE
Figure 2. Telephone defibrillator base station showing the con-
trol panel, and ECG display, chart recorder, and tape recorder
sub-units.
Figure 1. Prototype of the MD-phone'M telephone defibrillator:
a. standard 4 pin telephone jack connected to a 100 foot spool
of telephone wire stored in the upper lid connects the device
n I the telephone system; b. optional acoustic coupler to allow
a telephone handset connection to the telephone system; c.
hinge switch automatically turns device on, and automatically
dials the base station when the case is opened; and d. R-2 ECG
monitor-defibrillator electrodes. The outer white circumference
of the electrodes are adhesive, allowing them to stick to the VI-
V5 position on the patient’s chest.
several energy levels between 10 and 360 joules, and
discharges the defibrillator, if necessary via tone
code command. As a safety feature, the defibrillator
cannot be charged or discharged locally by the pa-
tient or lay witnesses.
The base station control panel of the telephone
defibrillator is similar to the controls of a standard
defibrillator, and uses the 1-select energy, 2-charge,
3-discharge system (Figure 3). Discharges either can
be synchronous or asynchronous. The control panel
also has controls to adjust the gain of the tele-
metered ECG, select impedance or respiration
(measured as the variation in transthoracic im-
pedance caused by breathing), and audio volume
controls for the speakerphone section.
The telephone defibrillator (TD) was tested in 17
patients at the electrophysiology laboratory, De-
borah Heart and Lung Center.5 VT or VF was in-
duced by programmed stimulation during serial
drug testing. R-2 adhesive ECG-defibrillator
monitor electrodes were attached to the patient,
enabling the patient’s ECG to be telemetered by the
TD patient unit to the base station, located in
another building on the Deborah campus. The re-
motely located monitoring physician made the
diagnosis of VT or VF from the telemetered ECG,
questioned the witnesses in the laboratory to de-
termine patient level of consciousness and whether
the witnesses were standing clear, and charged and
discharged the defibrillator to either synchronously
or asynchronously cardiovert VT or defibrillate VF
by telephone remote control. The TD system recent-
ly was FDA-approved in the United States for home
use by lay rescuers.
a b
c d
Figure 3. Base station control panel of telephone defibrillator
system: a. in case of inadvertent telephone disconnect, pressing
the upper button will cause the unit to automatically re-dial and
re-connect the patient unit to the base station; b. controls that
select impedence versus respiration telemetry, and set the gain
of the telemetered ECG; c. audio speaker phone volume con-
trols d defibrillator control section using the select energy,
charge, discharge system. Charge dump and synchronous
charge delivery also are selectable.
An example of telephone defibrillation is shown in
Figure 4. VT was induced by burst pacing and de-
generates to VF. The remote monitoring physician
diagnoses VF in 3.5 seconds, and then asks the wit-
ness if the patient is conscious. Note that speech
temporarily interferes with the ECG transmission.
Upon receiving a negative answer from the witness,
the physician checks electrode impedance that
measures 67 ohms indicating good electrode contact
(35 to 120 ohms is normal impedance for properly
applied electrodes), charges the defibrillator to 50
joules, and discharges the defibrillator converting
VF to normal sinus rhythm in a total time of 36
seconds. The touchtone control signals also interfere
briefly with ECG telemetry.
A total of 16 episodes of VT or VF and 4 episodes
of atrial fibrillation in 17 patients were successfully
VOL. 87— NUMBER 11 NOVEMBER 1990
875
pacing induced \ K onset v
Is the patient conscious?
J v^W>M/V < v'u v l; v j ;vt j •; — "/>aV . ■ ; _ :
■ . I jtZET
SLtj
>o
i- ; f +- r —
B® m
: .
Conn™ „ ,
standing dear standing dear
charge
select energs
A\y .v,V',V/wr,V.'.‘.V.o-% w.-e-
VAvtava/^oa
’
ecg amp. recovery
discharge 50 joules T
y>' r-
Figure 4. Example of telephone controlled defibrillation.
defibrillated or cardioverted by the remotely
monitoring physician using the TD system in a total
mean time from arrhythmia onset to shock termi-
nation of 47 ± 12.4 seconds. The mean ± SD time
required for the patient unit to dial the base station
was 13.0 ± 1.1 seconds. The time required for the
physician to diagnose VT or VF from the tele-
metered ECG was 3.3 ± 1.5 seconds. The mean time
required for the physician to question the witness
and to determine state of consciousness of the pa-
tient was 11.1 + 5.3 seconds, and the mean time
required to determine the witness was standing clear
was 7.0 ±1.4 seconds. The time required to charge
and to discharge the defibrillator was 12.6 ± 4.0
seconds.
The landline telephone defibrillator also has been
tested in Belfast, Ireland.6 Drs. Dalzell and Adgey
currently are testing a cellular telephone version of
the TD.7
AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
Figure 5. Example of Heart-Aid 1000 AED outpatient VT-VF
resuscitation. The AED contains a tape recorder and clock that
records the VF— shock — postshock ECG sequence for later
analyses.
identifying ventricular fibrillation, and a 95 percent
specificity for not shocking nonventricular fibrilla-
tion rhythms.9 Volunteer and basic level ambulance
technicians can be trained in the use of AEDs and
perform equally well to trained paramedics using
standard defibrillators.10 Lay witnesses also can
learn to use AEDs with good skill retention.11 13
We have used AEDs in five VT-VF patients re-
covering from amiodarone lung toxicity over a one-
to-two month period at home while awaiting suffi-
cient pulmonary recovery to enable lower-risk
thoracotomy for placement of an implanted de-
fibrillator. One of the five patients experienced VT-
VF at home and was successfully resuscitated by his
wife using an AED (Figure 5). He was admitted to
Deborah Heart and Lung Center and underwent
elective placement of an implanted defibrillator.
Another approach to out-of-hospital external de-
fibrillation is to incorporate an automatic com-
puterized VT-VF arrhythmia detector within an ex-
ternal defibrillator. These “smart” defibrillators,
also called automatic external defibrillators (AEDs),
require almost no user expertise. Cardiac arrest is
determined by the witness by observing absence of
respiration and pulse. The witness then applies the
self-adhesive ECG monitor defibrillation pads over
the patient’s chest and the device is activated by
merely turning it on. The AED analyzes the ECG
and reliably discriminates fast VT and VF from all
other non VT-VF rhythms. If fast VT or VF is pres-
ent, the AED will automatically charge and, depend-
ing on model, either will automatically deliver the
shock (fully automatic AED), or advise the user to
press a button that will deliver the shock (semi-
automatic AED).
The VT-VF algorithms within AEDs have proved
reliable in large-scale mobile rescue trials.8 They
typically have a 90 percent sensitivity for correctly
AICD DEVICES
The current, second generation (Cardiac
Pacemaker Inc.) Ventak 1550 Automatic Implanted
Cardioverter Defibrillator (AICD) is an improve-
ment over the initial first generation CPI 1510 and
1520 devices, and the original Intek Aid and AID-
BR devices. The Ventak 1550 pulse generator
usually is implanted under the skin of the left upper
quadrant of the abdomen because of its relatively
large size; it has an estimated battery longevity of
five years. The pulse generator usually is connected
to two screw-in type epicardial pacing leads to
provide bipolar rate sensing, and two patch elec-
trodes implanted over the left and right ventricle to
deliver the defibrillation energy (Figure 6). The de-
vice senses VT-VF by counting heart rate from the
rate sensing leads. The criteria for detecting VT-VF
is satisfied when the rate sensing lead counts a heart
rate greater than a programmable “rate cut off’ that
usually is set at 10 to 30 beats per minute slower
than the VT rate. In addition, a QRS morphology
876
NEW JERSEY MEDICINE
ietector circuit determines the probability density
unction (PDF) from the electrogram that it inputs
rom the patch electrodes. This feature either can be
programmed on or off. If on, both rate and PDF must
oe satisfied to deliver a shock. The device will de-
iver a first shock of 25 or 31 joules, which is pro-
grammable. If the first shock is unsuccessful at con-
certing the arrhythmia, a second through fifth
{shocks of 31 joules each will be delivered to termi-
nate the arrhythmia. The device currently delivers
a unidirectional, truncated exponential shock from
the LV apex patch (cathode) to the RV patch
(anode) as is shown in the upper left of Figure 6. The
shock is delivered in 8 to 15 seconds after sensing
VT-VF, and the device is “committed” to shock once
rate and, if programmed on, PDF is satisfied. The
device will deliver a shock once VT-VF criteria are
met, even if the VT stops spontaneously prior to the
6 to 8 seconds required for charging and then dis-
charging its capacitors into the patient.
There are several manufacturers developing future
AICD systems, and a number of these systems
already are in clinical trials. Improvements in future
AICDs and in the implantation techniques are sum-
marized briefly in Figure 6, showing the current and
possible future nonthoracotomy AICD implantation
techniques,14 defibrillation pulse delivery schemes,
VT-VF sensing algorithms, and incorporation of
backup VVI and antitachy pacing and other features
in future devices. Figure 6 also shows the shape of
the truncated exponential 25 to 31 joule waveform
used in presently available AICDs. New de-
fibrillators may use sequential, or biphasic shocks
that appear to be more effective than monophasic,
unidirectional shocks in converting VT-VF at lower
energy.
ELECTROPHYSIOLOGY TEST METHOD
Survivors of out-of-hospital VT-VF unrelated to a
specific, readily correctable cause, should undergo
invasive electrophysiologic (EPS) testing. Numerous
studies have shown that the EPS-directed therapy
is far more efficacious than empiric or Holter
monitor-guided drug therapy. The technique of EPS
testing is to place an electrode catheter in the right
ventricle and to apply one to three extra stimuli in
an attempt to induce VT or VF. If VT or VF can
be induced, the patient is retested after intravenous
or oral administration of antiarrhythmic drugs. If
VT or VF no longer is inducible after drug delivery,
the drug is shown to be efficacious. If VT or VF is
still inducible, the first drug is abandoned and,
serial drug testing with several other antiarrhythmic
drugs is tried. If a standard antiarrhythmic drug,
e.g. quinidine, Pronestyl™, mexiletine, cannot be
found that suppresses inducible VT or VF, the pa-
tient then is triaged to receive an automatic im-
planted defibrillator, antitachycardia pacer plus a
defibrillator, amiodarone drug therapy, or mapping
guided left ventricular aneurysmectomy or VT focus
ablation (Figure 7).
Of 100 consecutive VT-VF patients referred to De-
borah from January 1988 to March 1989, 48 patients
ultimately were controlled and treated by standard
antiarrhythmic drugs, 22 patients by amiodarone
therapy, 25 patients by AICD-antitachycardia
pacemaker therapy, and 6 patients by mapping
guided left ventricular aneurysmectomy. The EPS
Figure 6. Comparison of present and future automatic im-
plantable defibrillator system implant techniques, lead systems,
VT-VF detection algorithms, shock wave forms, and other fea-
tures. A nonthoracotomy lead system delivering a bidirectional
shock from a cathode on a “pacemaker-like” lead to two anodes
(one on the lead and one on a submuscular chest wall patch)
is shown in the upper right.
Role ol Invasive Electrophysiology
Studies
Serinl drug testing
Chronic oral iherapy-
drug suppressing
VT mducibility
48 patients
7 deaths
2 sudden death
22 patients
2 deaths
0 sudden death
Cardiac
electrosurgery
or catheter ablation
5 patients
0 death
0 sudden death
25 patients
1 death
0 sudden death
Figure 7. Results of treatment of 100 consecutive VT-VF pa-
tients at Deborah Heart and Lung Center using the elec-
trophysiology test method. Data for each subgroup are pres-
ented as total number of patients treated, and total deaths and
sudden deaths at one year mean followup for each subgroup.
VOL
87— NUMBER 11 NOVEMBER 1990
877
test method, EPS triage, and results of therapy for
these patients in a one-year followup are shown in
Figure 7. Our results are similar to other results
reported in the medical literature.
Our results suggest that amiodarone and AICD
therapy, and surgical ablation are more effective
therapy than standard antiarrhythmic drug therapy.
Because amiodarone is associated with a high in-
cidence of organ toxicity, we usually only use
amiodarone rather than implant the defibrillator in
older patients who are poor candidates for
thoracotomy. Because very few patients have
operable left ventricular aneurysms, and because
surgical risk of mapping guided aneurysmectomy is
in the 10 to 15 percent range compared to 2 to 5
percent for AICD surgery, far more patients are can-
didates for AICD than corrective surgery.
Technical improvements such as smaller size,
longer battery life, addition of antitachycardia and
brady pacing, development of all transvenous lead
systems, and easier, more cost-effective patient de-
vice followup by transtelephonic telemetry may ex-
pand the role of AICD therapy, and further diminish
the role of standard antiarrhythmic drug therapy
and amiodarone therapy in the future.
RISK STRATIFICATION
To date, the EPS test method has been clinically
applied to patients who are survivors of sustained
monoform VT and VF. These patients represent 5
percent of the total number of sudden death victims
in the United States per year.
AICD therapy intuitively seems to be the best
strategy for high-risk patients. However, the risk-
benefit ratio and the cost-benefit ratio of such an
approach may be too high. For example, approx-
imately 25 percent of the 400,000 survivors of acute
myocardial infarction per year in the United States
have low ejection fractions and frequent PVCs, and,
thus, are considered at high risk for sudden death.
To date, the AICD has been implanted in approx-
imately 10,000 patients worldwide, and already is
putting extreme stress on the medical reimburse-
ment and medical finance system. The cost of AICD
therapy is approximately $35,000 to $50,000 per pa-
tient with $17,000 for the generator and leads alone.
This cost, and small morbidity and mortality as-
sociated with AICD implants, would be dramatically
amplified if applied to large populations, such as the
high-risk postmyocardial infarction survivors.
An alternative approach is to treat high risk for
sudden death patients by training patient family
members to use a home defibrillator. These devices
cost approximately $5,000 per patient. Unlike anti-
arrhythmic drugs and AICD devices, automatic ex-
ternal defibrillators and telephone defibrillators are
noninvasive, and have no physicial proarrhythmic or
other side effects. Our preliminary data show that
AEDs can be operated by lay witnesses, and can save
lives. After a high-risk patient has his first clinical
episode of sustained VT-VF, and is saved by use of
a home defibrillator, the patient then could be
treated by the electrophysiology test method to
guide future antiarrhythmic drug, surgical, ablation,
or AICD therapy.
Widespread application of AEDs in nursing
homes, industry, transportation centers, public
arenas, trains, airplanes, volunteer ambulances, and
police and fire vehicles, and in the homes of high-
risk patients may allow for earlier defibrillation, and
an increase in the 5 percent save rate for out-of-
hospital sudden death. ■
REFERENCES
1. Stults KR, Kerber RE: Recent advances in out-of-
hospital defibrillation. Choices Cardiol 3:280, 1989.
2. Baum RS, et al.: Survival after resuscitation from
out-of-hospital ventricular fibrillation. Circulation
50:1231, 1974.
3. Eisenberg MS, et al.: Treatment of out-of-hospital
cardiac arrest with rapid defibrillation by emergency
medical technicians. N Engl J Med 302:1379, 1980.
4. Gessman LJ: Remote, telephone cardiac resusci-
tation device. US Patent #4,102,332, July 25, 1978.
5. Gessman LJ, Raman S, White MC, et al.: Initial
patient experience with telephone remotely controlled
cardioversion and defibrillation. J Am Coll Cardiol
11.-66A, 1988.
6. Dalzell G, Adgey AJ, et al.: Assessment of a device
for trans-telephone control of defibrillation. Lancet
1:695-697, 1988.
7. Dalzell G, Adgey AJ, et al.: Correction of cardiac
arrest outside hospital by remote defibrillation using a
cellular telephone. Pace 13:533, 1990.
8. Weaver D, et al.: Use of the automatic external de-
fibrilator. N Engl J Med 319:660, 1988.
9. Cummens RO, et al.: A new rhythm library for tes-
ting automatic external defibrillators: Performance of
three devices. J Am Coll Cardiol 11:597-602, 1988.
10. Stults KR, et al.: Efficacy of an automatic external
defibrillator in the management of out-of-hospital cardiac
arrest: Validation of the diagnostic algorithm and initial
clinical experience in a rural environment. Circulation
73:701-709, 1986.
11. Moore JE, et al.: Layperson use of automatic ex-
ternal defibrillation Ann Emerg Med 16:669, 1987.
12. Swenson RD, Weaver WD, et al.: Automatic ex-
ternal defibrillators used by family members to treat
cardiac arrest. Circulation 76:463, 1987.
13. Chadda K, Rammer R, et al.: Improved outcome
with the use of AED in the community setting. Pace 2:884,
1988.
14. Saksena S, et al.: Implanation of a cardioverter/
defibrillator without thoracotomy using a triple electrode
system. JAMA 259:69, 1988.
878
88
NEW JERSEY MEDICINE
Laser Energy for
Tachycardia Ablation
SANJEEV SAKSENA, MD
A step beyond pharmacologic therapy and conventional surgical ablation of
tachyarrhythmia foci, laser energy application presents an important new
development in the restoration of a stable cardiac rhythm.
While the greatest body of effort in anti-
arrhythmic therapy has been devoted to
pharmacologic measures, the concept of
nonpharmacologic therapy has existed for some
time. In the 1940s and 1950s, this led to the develop-
ment of artificial cardiac pacing for brady-
arrhythmias and electric shock therapy for reversion
of atrial and ventricular fibrillation. Effective treat-
ment of bradycardias by implantable cardiac
pacemakers on a chronic basis occupied attention in
the 1960s and the 1970s. In the last two decades,
recognition of tachyarrhythmias as a major source
of mortality and morbidity
in cardiovascular disease
Dr. Saksena is director, Ar-
rhythmia and Pacemaker Ser-
vice, Eastern Heart Institute and
clinical associate professor of
medicine, UMDNJ-New Jersey
Medical School, Newark. Re-
quests for reprints may be ad-
dressed to Dr. Saksena, Cardiac
Medicine and Electrophysiology,
201 Lyons Avenue, Newark, NJ
07112.
has been increasing. This heightened awareness has
accounted for the recent realization that a primary
cause of mortality in North America and Western
Europe, sudden cardiac death, most frequently is
due to ventricular tachyarrhythmias.1 It is estimated
that the sudden cardiac death syndrome affects
300,000 to 400,000 individuals in the United States
annually. It has been estimated that another 100,000
individuals are diagnosed annually with sustained
ventricular tachycardia, that may not necessarily
result in immediate mortality, but has a lethal
potential. Furthermore, supraventricular tachyar-
rhythmias are a frequent cause of morbidity result-
ing in hospital admissions as well as emergency room
visits. An estimated 800,000 individuals may be
treated annually for this disorder in the United
States. A subgroup of the latter, in whom the ar-
rhythmia is associated with ventricular pre-excita-
tion, e.g. Wolff-Parkinson-White syndrome, even
has the potential for a lethal outcome.
Current clinical experience with pharmacologic
therapy of tachycardias has been characterized by
limited efficacy and a lack of a clear rationale either
VOL. 87— NUMBER 11 NOVEMBER 1990
881
Thu 04 Jan 90 16:25:20
Figure 1. Computerized intraoperative epicardial activation
map in a patient with sustained ventricular tachycardia (VT) and
coronary artery disease. Fifty-six epicardial electrograms are
simultaneously recorded in a single VT beat. The cardiac apex
is in the center with the remainder of the ventricle displayed
laterally. Note that the earliest activation is at the cardiac apex
(location A) and in the anterolateral region Abbreviations: LAD
= left anterior descending coronary artery; RV = lateral right
ventricle; LV = lateral left ventricle. (Reproduced with per-
mission, J Interventional Cardiol, 1990.)
for drug selection or in the methodology used to
achieve it. Thus, this culminates in multiple anti-
arrhythmic drug trials and repeated hospital ad-
missions in individual patients. With the success of
implantable cardiac pacemakers in the chronic
treatment of bradyarrhythmias, nonpharmacologic
options for the treatment of tachyarrhythmias have
been actively evaluated. Therapeutic approaches
have included ablation, i.e. the arrhythmogenic
substrate is eliminated, or tachycardia reversion
using an implantable device. Ablation of the ar-
rhythmogenic substrate has become an increasing
attractive therapeutic option for many drug-refrac-
tory patients. It can provide a long-term cure and
eliminates the need for further antiarrhythmic ther-
apy. In the last decade, a number of new ablative
procedures have been evaluated for the therapy of
symptomatic supraventricular and ventricular
tachyarrhythmias. The development of cardiac
mapping that permits accurate identification of the
tissues resulting in tachycardia genesis dramatically
has enhanced the efficacy of surgical ablation
procedures.23 Computerized mapping systems now
are being clinically employed during the surgical
procedure (Figure 1). These systems make cardiac
mapping rapid, provide reproducible information,
and increase the potential application of tachycardia
ablation techniques. However, despite improve-
ments in our localization of the culprit tissues in the
heart, current ablative procedures have many limi-
tations. A large number of tachycardia sites of origin
either are not easily accessible during surgery or
cannot be fully resected. The mechanical resection
process is difficult to apply at sites such as the in-
traventricular septum, papillary muscles of the left
ventricle, or in the posterior left ventricle near the
valvular apparatus.4,5 As a result, a number of ad-
junctive techniques are being considered to enhance
the efficacy of surgical excision. One common tech-
nique currently employed is cryoablation.6 This
procedure is tedious and significantly prolongs
cardiopulmonary bypass time. This may have
adverse perioperative consequences.7 The efficacy of
the method, particularly in diseased human tissues,
is difficult to evaluate during surgery and the
method can be most effectively used in a cold
cardiopleged heart. This eliminates the possibility of i
analyzing the efficacy of ablation directly on the
tachycardia. Thus, it may be impossible to assess
the efficacy of the ablative procedure at the end of
the operation. There also is significant concern
about the myocardial effects of cryoablation that
may result in significant left ventricular dys-
function.8 At the present time, there is a continuing
search for new techniques that are more precise,
rapid, and less damaging to the myocardium to sim-
ultaneously enhance efficacy and reduce peri-
operative risk.
For the past six years, we have been evaluating
the use of catheter-delivered laser energy for the
ablation of supraventricular and ventricular tachy-
cardia.910 Use of laser energy for cardiovascular ap-
plication is increasing and laser angioplasty systems
are being applied clinically after extensive ex-
perimental evaluation. These angioplasty catheter
systems are being tested in peripheral and coronary
circulations.11 A variety of laser energy sources in-
cluding argon, Nd:YAG, or different excimer lasers
have been evaluated. It is expected that laser
angioplasty systems will enhance the applicability
of angioplasty procedures to more challenging dis-
ease situations such as totally occluded arteries, ar-
teries unresponsive to balloon angioplasty, or re-
opening of acutely thrombosed vessels. Presently,
most approaches utilize laser angioplasty in con-
junction with balloon angioplasty. Myocardial laser
ablation for arrhythmia suppression has been evalu-
ated experimentally for over five years. As a result
of these experimental studies, the feasibility of abla-
tion in atrial myocardium, normal human ven-
tricular myocardium, the specialized conduction
system, at the atrioventricular groove, and the dis-
eased human ventricular myocardium has been
demonstrated.12 14
Laser light is a stimulated emission of elec-
tromagnetic radiation and has several important
properties: it is coherent with the light waves being
in the same phase; it can be readily directed and
882
NEW JERSEY MEDICINE
collimated; it is monochromatic due to an extremely
narrow frequency range; and it can be focused and
directed into very small areas using lens and mirror
systems producing enormous power densities at the
sites of application. The use of laser ablation has
many theoretical advantages: it can be ac-
complished with a high degree of precision and con-
trol; the time required is far shorter than with other
methods; it can be accomplished in a normothermic
beating heart resulting in immediate assessment of
the effect of the ablation on the cardiac rhythm
(Figure 2); and at the end of the procedure, it is
possible to assess the effects of the ablative
procedure on tachycardia suppression. Experimen-
tal studies have demonstrated the feasibility of
argon and Nd:YAG laser ablation.91517 The argon
laser produces tissue vaporization. At the site of
laser discharge, a circular lesion with a central crater
surrounded by a coagulated rim of tissue is noted
(Figure 3). These lesions are sharp and heal by for-
mation of a homogenous scar that can reen-
dothelialize. Thus, endocardial ablation is feasible
as well as epicardial ablation (Figure 4). The
Nd:YAG laser, however, produces tissue photo-
coagulation at lower energies with tissue vapor-
ization occurring at higher energies. In our early
studies, we defined the dose-response relationship
for argon laser energy in myocardial ablation.
The size of myocardial lesion in both normal and
diseased myocardium in different media was stud-
ied.910 We have been able to define safe dose ranges
for endocardial ablation in atrial, normal ven-
tricular, or diseased ventricular myocardium. In dis-
eased human ventricular myocardium, perforation
was extremely uncommon even at energy densities
of 1000 J/cm2. Laser ablation results in elimination
of electrical activity in the ablated myocardium sec-
ondary to tissue necrosis and vaporization.15 Thus,
arrhythmogenic tissue can be made electrically
inert. Application of laser energy to the specialized
conduction system of the heart can result in
atrioventricular block, elimination of bypass tract
conduction may be feasible, and finally, ventricular
tachycardia ablation can be attempted.12,13 18 20 Effects
on myocardial function are extremely limited and
early experimental and clinical studies demon-
strated minimal deterioration in ventricular func-
tion.1617,20
INTRAOPERATIVE APPLICATION
Encouraged by our experimental studies, we ap-
plied for an experimental protocol for clinical appli-
cation in 1985. An investigational argon laser system
was employed in conjunction with a laser catheter
assembly. The FDA-approved clinical protocol was
initiated at Newark Beth Israel Medical Center and
now expanded to the Eastern Heart Institute,
Figure 2. Endocardial ablation of ventricular tachycardia
substrate in a patient with coronary artery disease. Preoperative
and intraoperative mapping localized the site of ventricular
tachycardia origin to the posterior wall of the left ventricle in this
patient. Intraoperative pulsed argon laser radiation to the left
ventricular endocardium at this site was used for endocardial
ablation. Note the transcatheter delivery of laser energy that
produces a series of adjoining endocardial lesions. (Repro-
duced with permission from Brachmann, Dietz, Kubler (eds),
Heart Failure and Arrhythmias, Heidelberg, FRG, Springer-Ver-
lag, 1990.)
Passaic. The laser catheter employed a quartz op-
tical fiber, and pulsed argon laser discharges were
used for myocardial ablation. Preoperative and in-
traoperative mapping were performed in all patients
to localize the arrhythmogenic substrate. The first
patient underwent myocardial ablation for ven-
tricular tachycardia in 1986. A total of 44 patients
now have undergone laser ablation for the treatment
of supraventricular and ventricular tachycardia.
Twenty-five patients have undergone laser abla-
tion of ventricular tachycardia. All patients had cor-
onary artery disease with a mean age of 62 years.
Twenty of these patients underwent concomitant
coronary artery bypass surgery and one patient
underwent mitral valve replacement for preoper-
ative severe mitral regurgitation. The mean left ven-
tricular ejection fraction was 35 percent. The sites
of ventricular tachycardia origin were in the anterior
or antero-septal left ventricle in 52 percent, in the
infero-posterior left ventricle in 38 percent, or in the
lateral left ventricle in 10 percent. A total of 51
ventricular tachycardias were ablated with an aver-
age of approximately 2 per patient. Normothermic
ablation during the induced ventricular tachycardia
was feasible and immediate cessation of ventricular
tachycardia was demonstrated (Figure 5). Laser
energy alone was used for ablation at 43 sites (84
percent). The remainder were ablated with either
laser energy combined with mechanical resection (12
percent) or mechanical resection alone (2 percent).
All patients had one or more ventricular tachy-
cardias ablated by laser energy alone. The peri-
operative 30-day mortality was 4 percent. This was
due to noncardiac causes. During followup, only two
VOL. 87— NUMBER 11 NOVEMBER 1990
883
N
Figure 3. Histologic section of a lesion induced by pulsed argon
laser discharges in a patient undergoing intraoperative laser
ablation of ventricular tachycardia. Note the crater with little
carbonization in diseased human ventricle [magnification of
photograph 30 times.] (Reproduced with permission, Catheter
Ablation of Cardiac Arrhythmias, Boston, MA, Martinus Nijoff
Publishing, 1988, p. 125.)
patients had recurrences of ventricular tachycardia
requiring further therapy. One patient became re-
sponsive to previously ineffective drug therapy and
the other patient received an implantable
pacemaker-cardioverter-defibrillator, Medtronic
model 7216A. There have been two deaths during
followup, one from gastrointestinal bleeding and
liver failure and a second patient died during sleep.
The latter has been classified as an unwitnessed
sudden death. The overall survival data are shown
in Figure 6.
The results of laser ablation for refractory ven-
tricular tachycardia compare very favorably with
the available information regarding other techniques
in current literature. The perioperative mortality for
map-guided subendocardial resection in the larger
series has ranged from 12 to 15 percent..4'8 The post-
operative sudden death rate has been 4 to 5 percent
annually and the recurrences of ventricular
tachycardia have been reported to be as high as 28
percent. Lower success rates for subendocardial re-
section have been noted in patients with inferior,
posterior, and septal sites of origin. Laser ablation
has the equivalent efficacy at all sites in the heart.
Other centers also have reported a high degree of
efficacy with laser ablation. Svenson employed a
Nd:YAG laser for surgical ablation of ventricular
tachycardia,21 with a cure rate of 100 percent
although the perioperative mortality was higher (12
percent). This may reflect the choice of laser energy
and patient selection. The long-term survival with
cryoablation also is significantly inferior to those
reported for laser ablation.8 The long-term survival
of cryoablation in a large multicenter series was 55
percent at three years.
In comparison to other nonpharmacologic modal-
ities for ventricular tachycardia, laser ablation re-
Figure 4. Epicardial and endocardial laser ablation in an exJ
cised bovine heart. Linear endocardial and epicardial ablative
lesions can be achieved using pulsed argon laser discharges.
(Reproduced with permission, PACE 9:547, 1986.)
mains an attractive choice. Catheter ablation of ven-
tricular tachycardia with direct current shock energy
has been reported to have a 5 percent perioperative
mortality, a 20 percent major complication rate, and
a 34 percent long-term failure rate in arrhythmia
suppression. While the two patient populations may
not be directly comparable, this provides consider-
able cause for reflection. The implantable
cardioverter-defibrillator has been shown to be high-
ly effective for prolonging arrhythmic survival in
patients with ventricular tachycardia or fibrillation.
While the sudden death mortality for patients re-
ceiving implantable cardioverter-defibrillators has
been reported to be less than 5 percent annually,
there is considerable controversy over the long-term
total survival of patients with such devices. Esti-
mates of five-year survival have ranged from 40 to
70 percent. When reviewing the early survival infor-
mation during intermediate-term followup, total
mortality was 18 percent at three years in our series
with laser ablation.19 While this, again, may not
necessarily reflect comparable patient populations,
currently available information would suggest laser
ablation is an effective therapeutic option for a well-
defined subset of patients with sustained ventricular
tachycardia.
Laser ablation for the treatment of supraven-
tricular tachycardia has been performed in 15 pa-
tients. Six of these patients had a documented ac-
cessory bypass tract and no evidence of other cardiac
disease. In these patients, the laser energy was used
for endocardial ablation and in 2 patients atrioven-
tricular groove dissection was achieved as well. One
patient had laser ablation alone for elimination of
bypass tract conduction whereas in 5 other patients
the combined laser and mechanical ablation
procedure was undertaken. Antegrade conduction in
five bypass tracts in 4 patients could be successfully
eliminated on a chronic basis with no recurrence
884
NEW JERSEY MEDICINE
Pre-Ablation
Sustained VT Cycle Length - 330 ms
^'V/VVVVVVVVVVVVVV/TV, V,
'• YrrmYnJr,-/Ymwrfrrm
A A A A A A '
During Laser Irradiation
Sustained VT Cycle Length - 400-420 ms
I
aVF
/■>VVVVVVVVVVVVVVVA/~Vv~V^
v6 /
Sustained VT Cycle Length • 420 ms Sinus Rhythm with A-v Block
l-v W+-A A4-V. A4— A A* — A A* A f, A A it t-
AAAAAAAAa
TimO*^",ul*i ■ ’MIII'I''ll!lnlillMlilllllll:llllill!illllllllllt!ll.!llllii:illlliiimmilllllllWII
|—1 sec -|
Figure 5. Effect of pulsed argon laser radiation on induced
sustained ventricular tachycardia. Intraoperative mapping-
guided endocardial ablation of diastolic electrical activity in the
left ventricular septum was performed in this patient. Note the
progressive slowing of the tachycardia that terminates after two
minutes of laser irradiation. This tachycardia subsequently was
suppressed postoperatively without spontaneous recurrence of
inducible tachycardia on laboratory testing. Abbreviations: ECG
leads I, a VF and V6 ; LV = left ventricular electrogram; A =
atrial electrogram; VT = ventricular tachycardia; A-V = atrioven-
tricular. (Reproduced with permission, J Interventional Cardiol,
1990.)
during followup. In 2 patients, recurrence of bypass
tract conduction was observed but in 1 patient it had
been modified sufficiently to prevent tachycardia
recurrence. The other patient became responsive to
antiarrhythmic drug therapy to which he had been
previously refractory. Nine patients had refractory
supraventricular tachycardia in the presence of
major organic heart disease. This included coronary
artery disease in 5 patients and cardiomyopathy in
4 patients. Ablation of atrioventricular nodal con-
duction was performed in 3 of these patients with
laser energy alone. Conduction could be interrupted
in 1 patient and modified in 2 patients. Permanent
pacemaker insertion after interruption of atrioven-
tricular nodal conduction was necessary in one pa-
tient only. Accessory bypass tract ablation was per-
formed in the remaining 6 patients. Successful inter-
ruption of conduction could be demonstrated in all
patients postoperatively. However, during followup,
resumption of bypass tract conduction was observed
in 2 patients of whom only one continued to have
recurrent tachycardia that now could be controlled
on previously ineffective drug therapy. Five of these
Survival following Laser VT Surgery
(Kaplan-Meler Life Table Method)
Arrhythmic - • — ♦ — ♦
Cardiac - * — * — *
Total - o — d — o
Figure 6. Life-table analysis of clinical outcome of study popu-
lation with refractory sustained ventricular tachycardia/ven-
tricular fibrillation using the Kapian-Meier method. Note the high
degree of arrhythmia control and survival in this population. One
patient was lost to followup and the cause of death was acute
myocardial infarction. This death is only shown in the total
survival data. (Reproduced with permission, J Interventional
Cardiol, 1990.)
patients with coronary artery disease underwent cor-
onary artery bypass surgery and there were signifi-
cant perioperative complications in this group.
These perioperative complications included patient
mortalities due to perioperative myocardial infarc-
tion secondary to graft occlusion, cardiogenic shock
due to pump failure, and acute respiratory failure
probably due to pulmonary embolism and deep vein
thrombophlebitis. One patient with Ebstein’s
anomaly died of delayed biventricular failure and
sepsis during followup. These complications ap-
peared to be directly related to the associated
myocardial disease and were unrelated to the laser
ablation. However, the feasibility of laser catheter
ablation alone for interruption of normal or
anomalous atrioventricular conduction has been
conclusively demonstrated. The importance of this
observation is related directly to the current direc-
tion of ablative therapy which utilizes percutaneous
catheter techniques.22 Since laser energy can be ap-
plied using a flexible catheter delivery system unlike
VOL. 87— NUMBER 11 NOVEMBER 1990
885
FUTURE DEVELOPMENTS
Figure 7. Laser catheter and angioscope assembly used in
early experimental work. (Reproduced with permission, PACE
9:534, 1986.)
mechanical energy or cryoablation, this has long-
term investigative importance.23
The major promise of laser catheter ablation is the
possibility of percutaneous use.23 The percutaneous
approach offers the promise of much greater patient
safety with the elimination of the need for open heart
surgery and its attendant risks. Current technologic
hurdles to the application of laser catheter ablation
need to be addressed, including the ability to per-
form adequate mapping using catheter delivery sys-
tems. The next major technologic obstacle to laser
catheter ablation is precise direction of the laser \
beam to the site of application. This is a more quan-
tifiable objective and visually and electrically
directed ablation is under evaluation (Figure 7).
Laser energy can be considered for both in-
traoperative application, particularly in situations
where standard surgical techniques are inadequate,
or as an adjunct to such techniques and in the future
for percutaneous catheter application. ■
REFERENCES
1. Cobb LA, Werner JA, Trobaugh GB: Sudden cardiac
death. Mod Concepts Cardiovasc Dis 49:31-36, 1980.
2. Durrer D, Schoo L, Scheilenberg RM, Wellens HJJ:
The role of premature beats in the initiation and termin-
ation of supraventricular tachycardia in the Wolff-
Parkinson-White syndrome. Circulation 36:644-649, 1967.
3. Josephson ME, Horowitz LN, Farshidi A, et al.: Re-
current sustained ventricular tachycardia: 2. Endocardial
mapping. Circulation 57:440-448, 1978.
4. Miller JM, Kienzle MG, Harken AH, Josephson ME:
Subendocardial resection for ventricular tachycardia: Pre-
dictors of surgical success. Circulation 60:624-629, 1984.
5. Saksena S, Hussain SM, Wasty N, et al.: Long-term
efficacy of subendocardial resection in refractory ven-
tricular tachycardia: Relationship to site of arrhythmia
origin. Ann Thor Surg 42:685-689, 1986.
6. Klein GJ, Sealy WC, Prichett ELC, et al.:
Cryosurgical ablation of the atrioventricular node-His
bundle: Long-term followup and properties of the junc-
tional pacemaker. Circulation 61:8-15, 1980.
7. Lawrie GM, Pacifico A, Kaushik R, et al : Does
amiodarone increase the risk of direct surgical ablation of
ventricular tachycardia? Circulation 80(IV):II-42, 1989.
8. Borggrefe M, Podczeck A, Ostermeyer J, et al.: Long-
term results of electrophysiologically guided anti-
tachycardia surgery in ventricular tachyarrhythmias: A
collaborative report on 665 patients, in, Breithardt G,
Borggrefe M, Zipes DP (eds), Non-Pharmacological Ther-
apy of Tachyarrhythmias. Mt Kisco, NY, Futura Publish-
ing Co., 1987, pp. 109-132.
9. Saksena S, Gadhoke A: Laser therapy for tachyar-
rhythmias: A new frontier. PACE 9:531-550, 1986.
10. Saksena S, Ciccone J, Chandran P, et al.: Laser
ablation of normal and diseased human ventricle. Am
Heart J 112:52-60, 1986.
11. Sanborn T, Faxon D, Haudenschild C, Ryan T:
Experimental angioplasty: Circumferential distribution of
laser thermal injury with a laser probe. J Am Coll Cardiol
5:934-938, 1985.
12. Narula OS, Bharati S, Chan MC, et al.: Micro-
section of the His bundle with laser radiation through a
pervenous catheter: Correlation of histologic and elec-
trophysiologic data. Am J Cardiol 54:186-192, 1984.
13. Narula OS, Boveja BK, Cohen DM, et al.: Laser
catheter-induced atrioventricular nodal delays and
atrioventricular block in dogs: Acute and chronic observa-
tions. J Am Coll Cardiol 5:259-267, 1985.
14. An HL, Saksena S: Comparative effects of radio-
frequency and laser ablation in normal and diseased ven-
tricular myocardium. J Am Coll Cardiol 13:175A, 1989.
15. Levine JH, Merillat JC, Stern M, et al.: The cellular
electrophysiologic changes induced by ablation: Com-
parison between argon laser photoablation and high-
energy electrical ablation. Circulation 76:217-225, 1987.
16. Saksena S, Hussain SM, Gielchinsky I, et al.: In-
traoperative mapping-guided argon laser ablation of ma-
lignant ventricular tachycardia. Am J Cardiol 59:78-83,
1987.
17. Lee B, Gottdiener JS, Fletcher RD, et al.: Trans-
catheter ablation: Comparison between laser photo-
ablation and electrode shock ablation in the dog. Circula-
tion 71:579-586, 1985.
18. Saksena S, Gielchinsky I: Argon laser ablation or
modification of the atrioventricular conduction system in
refractory supraventricular tachycardia. Am J Cardiol
66:767-700, 1990.
19. Krol RB, Saksena S: Laser ablation for supraven-
tricular and ventricular tachycardia: Present status and
future promise. J Intervent Cardiol , in press.
20. Saksena S, Gielchinsky I, Tullo NG: Argon laser
ablation of malignant ventricular tachycardia associated
with coronary artery disease. Am J Cardiol 64:1298-1304,
1989.
21. Svenson RH, Gallagher JJ, Selle JG, et al.:
Neodymium-YAG laser photocoagulation: A successful
new map-guided technique for the intraoperative ablation
of ventricular tachycardia. Circulation 76:1319-1328, 1987.
22. Scheinman MM: Catheter and surgical treatment
of cardiac arrhythmias. JAMA 293:79-82, 1990.
23. Saksena S: Catheter ablation of tachycardia with
laser energy: Issues and answers. PACE 12:196-203, 1989.
24. Saksena S, Lim F, Jr, Prasher S, An HL: Feasibility
of transcatheter argon laser ablation for ventricular
tachyarrhythmias. Circulation 76(11) :IV-278, 1987.
25. An H, Saksena S: Comparison of radiofrequency
and laser catheter ablation. Rev Eur Tec Bio 12:148, 1990.
NEW JERSEY MEDICINE
11
886
Cancer Research
in New Jersey
ANN MARIE HILL
FREDERICK B. COHEN, MD
The New Jersey State Commission on Cancer Research endeavors to sup-
port basic research in cancer by providing funds to New Jersey investigators.
The Commission now is focusing attention on the important area of clinical
research as well, including psychosocial and epidemiologic studies.
The New Jersey State Commission on Cancer
Research (NJCCR) was created by the
Cancer Research Act of 1983 to promote re-
search at nonprofit institu-
tions throughout the state
into the causes of cancer at
the molecular and cellular
level. Spurred by the
alarming mortality rates
cited for New Jersey in the
Ms. Hill is executive director,
New Jersey Commission on
Cancer Research and Dr. Cohen
is director of oncology, Newark
Beth Israel Medical Center and
chairman of the New Jersey
Commission on Cancer Re-
search. Requests for reprints
may be addressed to Ms. Hill,
Commission on Cancer Re-
search, 28 West State Street,
Room 714, CN 360, Trenton, NJ
08625-0360.
“Atlas of Cancer Mortality for U.S. Counties,
1950-1969,” and concern that New Jersey was not
attracting its fair share of federal research dollars,
the Act concluded: “Benign neglect had been re-
sponsible for delaying the development of services
and facilities necessary to conduct productive re-
search.” The law insisted that “corrective measures
should be adopted promptly and funded adequately
to make up for lost ground.” It charged the Com-
mission with taking the necessary steps to make
New Jersey competitive in the area of cancer re-
search. Dedicated funds of $1 million, appropriated
annually from the cigarette surtax, were provided to
effectuate the purposes of the act.
Originally nine Commission members, including
representatives from the medical, scientific, and
business community, were appointed by the gov-
ernor with the consent of the Senate; in 1985, an
amendment expanded membership to 11 persons.
The first task of the newly formed Commission
was to decide how best to carry out its mandate.
Lewis Thomas, MD, president emeritus of Memorial
VOL. 87— NUMBER 11 NOVEMBER 1990
889
Return on Investment
890
NEW JERSEY MEDICINE
Sloan-Kettering, has pointed out, “Almost by defi-
nition basic research is unpredictable and this is
especially true for the kinds of fundamental inquiry
relevant to the problem of cancer.”1 It, therefore,
would be difficult, if not impossible, to set in ad-
vance an infallible course for the future. After
serious thought, the Commissioners agreed that the
only sure way of approximating this in cancer re-
search is to invest in talented people. After consider-
ing a variety of alternatives, it was agreed that a
competitive grant program providing seed money for
promising new investigators or established in-
vestigators embarking on new areas of research
would be the most effective use of the NJCCR funds.
Through the preliminary data derived from such
grants, it was expected that researchers would be
better equipped to compete in the national arena.
A system of rigorous review carried out by world-
renowned cancer researchers from outside the state
was designed to evaluate the quality of applications.
Based upon this scientific review, grants were
awarded.
Since its first cycle in 1984, the Commission has
awarded over 120 grants at a total cost of $7.2
million. Most of these grants have been basic labora-
tory studies covering a vast array of topics including
almost every subdiscipline of cancer.
It often is difficult to determine the impact of
funding for cancer research. Small parts may be-
come important pieces in the larger puzzle. How-
ever, the Commission sees its support as an invest-
ment for the state, and actively tracks the national
funding generated from its grants. While it takes
almost three years before preliminary data are avail-
able and applications are completed, the return on
investment from Commission grants appears to be
close to $3 for every $1 provided (Figure).
The original terms of the Cancer Research Act
stipulated that an appropriate research project
would have to focus on the genetic, biochemical,
viral, microbiological, and environmental causes of
cancer. Not included in the original classification
were behavioral, epidemiological, psychosocial, or
clinical studies. In a meeting with representatives of
the National Cancer Institute in 1984, it was rec-
ommended that the Commission broaden its man-
date to include these areas. It was recognized that
the unique geographical size, the demographics, and
its high rates of certain cancers made New Jersey
an almost perfect natural laboratory. Such a wider
scope would allow the Commission to deal with the
cancer problem in the state on several fronts. In
1985, a bill to this effect was signed by former Gov-
ernor Thomas Kean.
While this broadened mandate secured a more
realistic mission for the Commission, it also brought
into question the adequacy of its funding base. It
became obvious that the Commission would be un-
able to establish a balanced program without de-
pendable, sufficient funding. With this in mind, the
Commission appealed to former Governor Kean and
the Legislature to increase funding for cancer re-
search. In response, the Commission’s budget has
been supplemented with additional appropriations
of $1 to 2 million per year between 1985 and 1989.
To parallel these developments, the Commission
and Senator Frank Lautenberg cosponsored, “A
Working Conference on Cancer Research in New Jer-
sey.” One hundred forty cancer experts from
throughout the state identified the needs of cancer
research in New Jersey and made recommendations
to address these needs. The findings from this con-
ference were presented in a major report in 1987. At
the same time, the Commission established six ad-
visory groups, representing major areas of research,
charged with bringing the recommendations in the
report to fruition.
The advisory groups that include basic research,
control and prevention, clinical, pediatrics, psy-
chosocial/nursing, and radiation biology research
have pursued independent strategies with the sup-
port of the Commission. The basic research advisory
group worked hand in hand with the Commission to
establish the New Jersey Cancer Research Fellow-
ship. This program is designed to attract talented
young scientists to institutions in New Jersey and
to fill a vacuum created by reduced funding at the
federal level for such activities. A 1985 survey con-
ducted in response to an American Cancer Society
report indicated that New Jersey requires four times
as many fellows as it presently has to reach national
averages. The program employs the same rigorous
review process as the grant program. To date, 50
post- and predoctoral fellows have been supported
by the Commission.
Recognizing that New Jersey offers unique op-
portunities for special topics of concern, the Com-
mission initiated the Cancer Research Development
Program in 1988. This program seeks to stimulate
research in identified areas of significant interest for
New Jersey, encourages collaborative and coopera-
tive research, and provides seed money for pilot
studies identified as priorities for future spending by
national agencies. The Cancer Control and Preven-
tion Advisory Group assisted the Commission in de-
veloping its first two topics, cancer among the eco-
nomically disadvantaged and cancer and radon. Six
grants were awarded including an evaluation of
black and disadvantaged individual cancer data; a
study of immune status and breast carcinoma in
minority patients; an investigation of cancer risk
factors in Hispanics, whites, and blacks in Newark;
a project on preventive oncology conducted in the
Newark and East Orange school districts; a study
VOL. 87— NUMBER 11 NOVEMBER 1990
891
of radon-induced DNA damage in maternal and
fetal tissues; and an assessment of human exposures
to radon and radon progeny using personal monitor-
ing. The results of these studies are preliminary.
However, the experience gained in pursuing these
projects will provide a base upon which New Jersey
will build its research capabilities and be better
equipped to solve these serious problems.
As the survival time for patients with cancer has
increased, it has become imperative to deal with the
social and psychological needs and problems of
cancer patients. Research on such concerns is not
developed at this time. The psychosocial/nursing ad-
visory group has sponsored a series of conferences in
which participants were encouraged to suggest re-
search topics. As a result, the group has initiated
several projects including the establishment of a
psychosocial database for cancer patients.
In the clinical arena, the activities of the New
Jersey Pediatric Hematology Oncology Network and
the Cooperative Oncology Group of New Jersey have
pursued parallel strategies. Both groups have sought
to develop cooperative clinical trials within the
state. The Network assures that children diagnosed
with cancer in New Jersey are enrolled in national
study groups. Finally, the group is negotiating with
representatives from the pharmaceutical industry to
undertake studies involving new technologies that
may bring further benefits to children with cancer
in New Jersey.
With several hundred physicians practicing in
New Jersey having backgrounds in clinical research,
the New Jersey Commission on Cancer Research
encouraged the formation of the Cooperative On-
cology Group of New Jersey (COGNJ). The objec-
tives of the group include: bringing the advantages
of research to patients in their own communities by
permitting practicing physicians to participate in
clinical research protocols; providing patients with
new treatments as soon as they are available; reduc-
ing mortality by accelerating the community appli-
cation of new treatments; allowing New Jersey on-
cologists to become expert in the use of new tech-
niques and treatments; acquainting all New Jersey
practitioners, even those not involved in research,
with modern cancer treatments; encouraging clinical
investigation of new products of New Jersey com-
panies and laboratories and speeding the transfer of
information from laboratory to clinic; educating the
public in methods of cancer control and early detec-
tion; and contributing to the universal body of
knowledge on human cancer. Under a contract from
the Commission, the American College of Radiology
provides administrative and statistical support for
COGNJ. Development of protocols for breast, colo-
rectal, and lung cancers began in July 1989. The
group also became a subcontractor of the National
Surgical Breast Adjuvant and Bowel Project
(NSBABP) so patients treated for breast and colon
cancers could be entered into adjuvant therapy
trials. The group plans to expand with additional
clinical trials in New Jersey, to be adopted each year
for the next five years.
While it is clear that New Jersey has progressed '
substantially in its ability to mount a significant
attack on its cancer problems, the resources neces-
sary for such an effort have been lacking. It was
recognized almost immediately that a permanent
base of $1,000,000 per year is not sufficient to meet
the needs of a sophisticated research program. Each
year the Commission has been forced to seek sup-
plemental funding through the state Legislature to
maintain the minimum level of its activities. This
places cancer research in New Jersey within the po-
litical arena where it can be affected by multiple
factors often unrelated to the war against cancer, but
able nonetheless to impede its progress. Since re-
search projects require several years to complete,
funding must be stable and long term. Further, a
concerted effort to expand the state’s reservoir of
young scientists must continue. Only through the
enactment of a long-term (at least five years) plan
can we hope to achieve the goal of reducing cancer
mortality by 50 percent in New Jersey by the year
2000. To this end, the Commission has developed a
five-year comprehensive research program to ad-
dress the state’s needs in basic, clinical, psy-
chosocial, and nursing as well as epidemiologic and
environmental research. This will require a commit-
ment of $5 million per year from the estimated $180
million derived from the new cigarette taxes.2 The
Commission feels strongly that it is a small invest-
ment to reap rich returns.
The New Jersey State Commission on Cancer Re-
search (NJCCR) has made remarkable strides over
the past seven years. Through its activities, state-
sponsored cancer research has become a reality in
New Jersey. NJCCR has been heralded by the Na-
tional Cancer Institute and the National Cancer Ad-
visory Board as a national model. But, New Jersey
does not yet have the kind of dedicated resources to
support its programs. New Jersey is at a critical
stage in the war against cancer. What remains to be
done to complete the job is to secure funding that
is both stable and sufficient for a long-term program.
Nothing less can guarantee success. ■
REFERENCES
1. Report: “Amercian Business Foundation for Cancer 2. Estimated by Office of Legislative Services, A3608,
Research, Inc.” Westport, Connecticut, 1986. 1990.
892
NEW JERSEY MEDICINE
Biologic Therapy
of Cancer
ALAN W. DUNTON, MD DANIEL LEVITT, MD, PhD
JOHN HANAGAN, MD ROBERT J. SPIEGEL, MD
JACOB ZEFFREN, MD
Developments in molecular biology and ad-
vances in understanding tumor biology and
the immune system promise to make the
1990s an exciting decade in medical approaches to
cancer. We enter the 1990s with a newly enhanced
armamentarium and new targets for drug develop-
ment. The major areas of interest spurring new
enthusiasm are: increased understanding and identi-
fication of oncogenes as potential targets for new
drug development; new understanding of multidrug
resistance and targeted programs; the coming of age
of immunotherapy with alpha interferon as the first
approved biological for oncology and interleukin-2 as
well as monoclonal antibodies as novel approaches
Drs. Dunton (top, left) and Hanagan (top, right) are affiliated with
CIBA-GEIGY Corporation; Dr. Zeffren (bottom, left) is affiliated
with Hoffmann-La Roche, Incorporated; Dr. Levitt is affiliated
with Sandoz Pharmaceuticals; and Dr. Spiegel (bottom, right)
is affiliated with Schering-Plough Corporation. Requests for re-
prints may be addressed to Dr. Dunton, CIBA-GEIGY Corpor-
ation, 556 Morris Avenue, Summit, NJ 07901.
for recruiting the body’s immune system to eradicate
cancer cells. Added to this is our explosive growth
in understanding the immune system’s regulatory
effector cells and their controlling factors and the
availability of agents that literally can titrate a pa-
tient’s hemoglobin, granulocytes, and macrophages
at the physician’s discretion.
The pharmaceutical industry has identified on-
cology as a major therapeutic area for development
and enters the 1990s in a very different posture than
a decade ago. The most visible and publicized aspect
of this change is the emergence of dozens of startup
biotechnology companies whose research base is
built upon monoclonal antibodies or recombinant
DNA technology with diagnostic or therapeutic
targets in oncology. However, many of the estab-
lished pharmaceutical companies also have estab-
lished major research and development programs in
oncology in the last decade.
INTERFERONS
Interferons are proteins that regulate cell function,
slow cell proliferation, and inhibit viral replication.1
Three major classes of interferons (alpha, beta, and
gamma) have been defined on the basis of physical,
chemical, antigenic, and biological differences. By
use of recombinant DNA techniques, a complete
nucleotide sequence for alpha interferon was de-
fined,23 and a family of more than 17 physico-
chemically related interferon alpha proteins now has
been defined.4-5
The first clinical trial of recombinant alpha inter-
feron began in the early 1980s. In this trial and
subsequent studies, the safety and efficacy of this
compound as a single agent was investigated in the
treatment of multiple solid and hematologic malig-
nancies as well as other conditions, e.g. hepatitis.
Alpha interferon (both 2a and 2b subspecies) has
been found to be a highly effective single agent for
the treatment of hairy cell leukemia and chronic
leukemia of B-cell origin. This compound was ap-
proved in 1986 for marketing for this indication by
VOL. 87— NUMBER 11 NOVEMBER 1990
895
the Food and Drug Administration (Roferon"-A and
Intron"-A). Approximately 80 to 90 percent of
treated patients experience a partial remission, and
complete remissions are observed in approximately
5 percent of such treated patients. But antitumor
activity has not been restricted to hairy cell
leukemia, a fairly uncommon neoplasm. Encourag-
ing results have been observed in a number of
hematologic malignancies including chronic myelo-
genous leukemia, multiple myeloma, non-Hodgkin’s
lymphoma, and myeloproliferative disorders.68'2
Interferon also has been found to be useful in the
treatment of some solid tumors. Approximately 20
percent of patients with disseminated renal
adenocarcinoma have experienced complete or
partial responses to alpha interferon.9 Similar
response rates have been observed in patients with
metastatic malignant melanoma.10 Response rates of
25 to 30 percent have been observed in patients with
AIDS-related Kaposi’s sarcoma treated with high
doses of alpha interferon." On the basis of this data,
Roferon“-A and Intron"-A were approved for the
treatment of select patients with AIDS-related
Kaposi’s sarcoma.
For most therapeutic agents in cancer, combina-
tions frequently are more efficacious than single
agents. The combination of alpha interferon with
cytotoxic or other biological entities is being vigor-
ously pursued, and already has yielded encouraging
results. Wadler and colleagues have treated patients
with colorectal carcinoma with a combination of
alpha interferon and 5-fluorouracil; in 32 previously
untreated patients with metastatic disease, 20 pa-
tients had partial responses."' The combination of
alpha interferon and zidovudine in patients with
AIDS-related Kaposi’s sarcoma has enabled the use
of lower and less toxic doses of alpha interferon, and
combining alpha interferon with pentostatin has
caused responses in patients with cutaneous T-cell
lymphoma who are refractory to other therapy.14
Alpha interferon in combination with dacarbazine
has produced both complete and partial responses
in patients with metastatic melanoma.15 A study of
particular interest is the combination of alpha inter-
feron with 13-cis retinoic acid (Accutane") in pa-
tients with advanced squamous and basal cell skin
cancer. Retinoic acid, a naturally occurring
metabolite of vitamin A, is an agent of cell differen-
tiation that has been found useful in some
hematologic disorders such as myelodysplastic (pre-
leukemic) syndromes. Its major utility, however, has
been in skin disorders. Patients with squamous or
basal cell skin cancer have experienced significant
disease regression with 13-cis retinoid acid, and the
combination with alpha interferon is being pursued.
CGP 35269, a recombinant human alpha inter-
feron, consists of amino acid sequences of both the
B and D subspecies. Phase I trials have defined
subjective and objective side effects that occur with
its use. The quantitative frequency of side effects
among patients and the qualitative nature of toxi-
cides, have been equivalent to that observed with
partially purified and purified interferons.1617
However, the frequency of dose-limiting side ef-
fects, such as fatigue and anorexia, significantly
were less after alpha interferon D administration
than after alpha interferon A administration.18
INTERLEUKINS
A second area of biological therapeutic research
involves the development of recombinant inter-
leukin-2 (rIL-2) as an anticancer agent. Inter-
leukin-2, a protein produced by activated T-
lymphocytes, plays a central role in mediating many
specific immune responses, as well as having the
ability to stimulate the proliferation and function of
cells useful in tumor regression. Naturally occurring
interleukin-2 is present in insufficient amounts in
the body to enable adequate study. The gene for
human IL-2 production, therefore, was isolated,
cloned, and inserted into the genetic material of E.
coli, in a manner similar to that utilized for the
production of alpha interferon. This recombinant
product (rIL-2) was purified and readied for human
clinical trials. As popularized by Dr. Steven Rosen-
berg, rIL-2, utilized either as a single agent or in
combination with activated lymphocytes (LAK
cells), was found to cause objective antitumor
responses in 10 to 30 percent of patients with dis-
seminated renal adenocarcinoma or malignant mel-
anoma.19 However, Dr. Rosenberg utilized a dosing
regimen that required intensive care for many pa-
tients because of significant toxicity. The clinical
utility of this compound in a variety of doses and
regimens, both as a single agent and in combination
with LAK cells, has been investigated further. The
antitumor effects in a small percentage of patients
with renal adenocarcinoma have been observed. It
appears that rIL-2 is effective utilized as a single
agent or in combination with LAK cells (adoptive
immunotherapy). The requirement for LAK cells
necessitates a sophisticated laboratory setting for
the large-scale generation of these cells in a sterile
environment. This may preclude the widespread
usefulness of this mode of therapy by oncologists in
the community. Additionally, higher doses of rIL-2
seem to be required to achieve objective responses
in patients with malignant melanoma.
One of the most exciting aspects of the clinical
development of rIL-2 has been the possibility of in-
creased efficacy observed when this agent is com-
bined with alpha interferon. Preclinical experiments
indicate that the combination of the two agents
seems to possess enhanced antineoplastic activity,
896
NEW JERSEY MEDICINE
as compared to each agent utilized separately. The
mechanisms of this activity are uncertain but may
include heightened expression of tumor cell surface
antigens and stimulation of the activity of cytolytic
cells. A large-scale clinical program utilizing the
combination of these two agents in a variety of ma-
lignant conditions is underway. Thus far, early re-
sults indicate superior efficacy for the combination
as compared to single agent rIL-2. More impor-
tantly, the studies are utilizing doses that are more
tolerable and, therefore, can be administered on an
outpatient basis. Recombinant IL-2 can be success-
fully administered by a portable infusion pump for
prolonged periods of time, allowing continuous in-
travenous treatment, if required. This has allowed
the investigation of long-term, low-dose continuous
intravenous treatment with rIL-2.-° If the efficacy of
the combination of these two agents is significant,
and if a tolerable and easily administered outpatient
regimen can be formulated, this would be an impor-
tant advance in the treatment of malignancies that
have no established therapy.
Another aspect of biological therapy that has been
approached is the combination of rIL-2 with other
modes of therapy, particularly cytotoxic chemo-
therapy. The combination of cisplatin and etoposide
with rIL-2 is being evaluated in the treatment of
patients with non-small cell lung cancer, as well as
a second similar regimen that includes cyclophos-
phamide. rIL-2 also has been combined with mono-
clonal antibodies in the treatment of patients with
malignant melanoma. In addition, rIL-2 has been
evaluated with gamma interferon in the treatment
of solid tumors refractory to other therapy. Cisplatin
has been added to the rIL-2/alpha interferon com-
bination for the treatment of malignant melanoma,
and cyclophosphamide has been added to the
biological agent combination in the treatment of
disseminated solid tumors. Fluorouracil has been
added to the combination for the treatment of colon
cancer patients, and other such combinations are
being studied for the treatment of breast and head
and neck cancer.
COLONY-STIMULATING FACTORS
A major consequence of most drugs used for cancer
chemotherapy is suppression of blood cell formation,
especially cells of the granulocyte and platelet lin-
eage. Within the past decade, a number of proteins
have been identified that exhibit remarkable abili-
ties to stimulate growth and function of hematopoi-
etic precursors. These molecules, designated colony-
stimulating factors, are expected to alleviate bone
marrow suppression induced by toxic chemothera-
peutic regimens and permit patients to receive high-
er doses and more courses of their anticancer treat-
ment.
The genes for several colony-stimulating factors
have been isolated and the recombinant proteins
themselves have been produced in large quantities
in E. coli that contain the CSF genes. This has
permitted their use in a variety of clinical oncology
trials.
Granulocyte-macrophage colony-stimulating fac-
tor (GM-CSF) has been tested in a wide variety of
clinical settings in patients receiving autologous and
allogeneic bone marrow transplants. GM-CSF ap-
pears to shorten the duration of neutropenia and also
hospitalization as well as decrease the incidence of
serious infections in these patients. Myelodysplastic
syndrome, a bone marrow disorder associated with
myeloid and platelet agenesis also seems to respond
to GM-CSF therapy. Generation of higher numbers
of neutrophils and decreased incidence of infections
are associated with treatment, and benefit ceases
when administration of GM-CSF is halted.
GM-CSF also is being evaluated presently in pa-
tients receiving intensive chemotherapy to reduce
the nadir and duration of neutropenia and thereby
will permit patients to have more prolonged and
intense treatment with potentially effective an-
ticancer drugs.
Interleukin-3, multi-CSF, stimulates early
hematopoietic progenitor cells in the bone marrow
to proliferate and later differentiate in response to
other cytokines. Testing of recombinant human IL-3
recently has been initiated as a single agent or in
combination with GM-CSF as therapy for patients
receiving bone marrow transplants, for
myelodysplastic syndrome and aplastic anemia, and
for patients receiving intensive chemotherapy regi-
mens. It is expected that IL-3 will expand early
precursor pools of blood cells that will differentiate
more rapidly and in greater numbers upon adminis-
tration of CSFs that stimulate cells that arise later
in the hematopoietic lineage. However, it is more
significant that this approach signals the advent of
therapy using combinations of biological molecules
that will minimize specific risks of intensive treat-
ment with chemotherapy and radiation. This new
path could enhance tumor responses by allowing
patients to receive more extreme cancer treatment
regimens.
ENDOCRINE TUMORS
Endocrine tumors, especially those of neu-
roendocrine origin, have been a significant focus for
drug development. The somatostatin analog, oc-
treotide (Sandostatin®), has a longer half-life and
induces fewer side effects than the parent com-
pound, yet is remarkably effective therapy for cer-
tain rare tumors known as VIPomas (tumors that
secrete vasoactive intestinal peptide) and metastatic
carcinoid tumors. This drug also is being tested for
VOL. 87— NUMBER 11 NOVEMBER 1990
897
its effectiveness in diminishing the severe diarrhea
associated with AIDS as well as other disorders of
gastrointestinal hypersecretion.
Several solid tumors, including breast cancer and
lung cancer, express receptors that will bind
somatostatin. It is not known whether these recep-
tors possess growth regulatory functions and can be
suppressed by exposure to somatostatin, but this
possibility is being evaluated. Further, the presence
of such surface markers on some solid tumors serves
as the basis for a novel diagnostic approach. Oc-
treotide has been coupled to the radioisotope indium
and injected into animals that carry tumors with
somatostatin receptors. Within hours, the tumor can
be clearly detected by radionuclide scanning and
background emission is minimal due to the limited
distribution of radionuclide (kidneys and bladder
only). Similar approaches using monoclonal anti-
bodies have been hampered by high background
counts observed in the lungs, liver, and kidneys.
MULTIDRUG RESISTANCE
There is clear evidence that cancer cells either
start out or become resistant to the cytotoxic drugs
used to destroy them. In many instances, the same
cancer cells are resistant to a broad spectrum of
agents that possess neither structural nor functional
similarities. This resistance, designated multidrug
resistance (MDR) has been demonstrated to be
mediated by a specific glycoprotein of 170,000 dalton
molecular weight. This glycoprotein, known as P170,
is a drug efflux pump that possesses 12 trans-
membrane domains as well as two ATPase catalytic
sites.
A number of drugs, including calcium channel
blocking agents, calmodulin inhibitors, and
cyclosporine A, will inhibit the ability of the P170
to remove cytotoxic drugs and can effectively reverse
the MDR phenotype of many cancer cell lines in
vitro. This activity also can be demonstrated for
MDR tumors transplanted into mice in vivo. Since
most agents that will inhibit MDR also possess other
potent pharmacologic activities (cardiovascular ef-
fects, sedation, and immunosuppression), analogs of
cyclosporine A (Sandimmune®') have been evaluated
that will block MDR without causing immunosup-
pression. Several compounds have been identified
that are active in vitro and in mouse tumor models
in vivo; these agents will enter clinical trials in the
near future.
CONCLUSION
Significant efforts are being made by the New
Jersey pharmaceutical industry directed not only at
developing clinically useful drugs but also at
answering the basic scientific questions in the field
of oncology that will enable scientists to develop the
therapies of the future. ■
REFERENCES
1. Baron S, Dianzani F, Stanton GJ, Fleishman WR Jr
(eds): The Interferon System. Austin, TX, University of
Texas Press, 1987.
2. Mantei N, Schwarzenstein M, Streuli M, et al.: The
nucleotide sequence of a cloned human leukocyte inter-
feron cDNA. Gener 10:1-10, 1980.
3. Goeddel DV, Yelverton E, Ullrich A, et al.: Human
leukocyte interferon produced by coli is biologically active.
Nature 287: 411-416, 1980.
4. Nagata S, Mantei N, Weissman C: The structure of
one of the eight of more distinct chromosomal genes for
human interferon alpha. Nature 287:401-408, 1980.
5. Goeddel DV, Leung DVV, Dull TJ, et al.: The struc-
ture of eight distinct cloned leukocyte interferon cDNAs.
Nature 290:20-26, 1981.
6. Talpaz M, McCredie K, Kantarjian H, et al: Chronic
myelogenous leukemia; hematological remissions with
alpha interferon. Br J Haematol 64:87, 1986.
7. Talpaz M, Kantarjian HM, McCredie K, et al.:
Hematologic remission and cytogenetic improvement in-
duced by recombinant human interferon alpha-A in
chronic myelogenous leukemia. N Engl J Med 314:1065,
1986.
8. Talpaz M, Kurzrock R, Kantarjian H, et al.: Recom-
binant interferon-alpha therapy of Philadelphia
chromosome-negative myeloproliferative disorders with
thrombocytosis. Am J Med 86:554, 1989.
9. Buzaid AC, Todd MB: Therapeutic options in renal
cell carcinoma. Sem Oncol 16:12, 1989.
10. Legha SS: Current therapy for malignant mela-
noma. Sem Oncol 16:34, 1989.
11. Krown SE: Approaches to interferon combination
therapy in the treatment of AIDS. Sem Oncol 17:11, 1990.
12. Olsen EA, Rosen ST, Vollmer RT, et al.: Interferon
alpha-2a in the treatment of cutaneous T-cell lymphoma.
J Am Acad Dermatol 20:395, 1989.
13. Wadler S, Wiernik PH: Clinical update on the role
of fluorouracil and recombinant interferon alfa-2a in the
treatment of colorectal carcinoma. Sem Oncol 17:16, 1990.
14. Foss F, Fischmann A, Schechter G, et al.: Phase II
trial of pentostatin and interferon alfa-2a in advanced
mycosis fungoides/sezary syndrome. Proc ASCO 8:276,
1989.
15. Bajetta E, Negretti E, Gianotti B, et al.: Phase II
study of interferon alpha-2a and dacarbazine in
metastatic melanoma. Proc ASCO 8:286, 1989.
16. Gutterman JU, Fein S, Queseda J, et al.: Recombi-
nant human leukocyte A interferon: Pharmacokinetics,
single-dose tolerance, and biological effects in cancer pa-
tients. Ann Intern Med 96:549-556, 1982.
17. Scott GM, Secher DS, Flowers D, et al.: Toxicity
interferon. Br Med J 282:1345-1348, 1981.
18. Hawkins MJ, Borden EC, Merritt JA, et al.: Com-
parison of the biological effects in man of two recombinant
human interferon alpha (rA and rD). J Clin One 2:221-226,
1983.
19. Rosenberg SA: The development of new im-
munotherapies for the treatment of cancer using inter-
leukin-2. Ann Surg 208:121, 1988.
20. Ritz J, personal communication.
898
NEW JERSEY MEDICINE
Responsible Weight
Loss in New Jersey
MARVIN A. KIRSCHNER, MD
GEORGE SCHNEIDER, MD
NORMAN ERTEL, MD
ANTON HEINS, III, MD
PATRICIA MCALEAVY, MSW
MARYANN MERRELL, RD
Very low-calorie formula diets (VLCDs) are an accepted method of achieving
safe and effective weight loss for the morbidly obese. Under supervised
medical surveillance and with a support team of dietitians and patient coun-
sellors, weight loss of 40 or more pounds is achieved in 80 percent of
patients. The authors present guidelines for assessing responsible weight
loss programs along with a list of programs available in New Jersey.
Obesity represents a major health hazard.15
In 1956, approximately 16 percent of
American men were estimated to be obese
and 5 percent were severely obese;5 in women, the
numbers are greater, with 42 percent of women
classified as obese or severely obese. Data from the
National Health and Nutrition Education Survey II
(NHANES) demonstrate the problem is intensify-
ing; a third NHANES study is underway, with
emphasis on inner-city residents in whom obesity
approaches epidemic proportions. The medical com-
plications of obesity include accelerated cardio-
vascular disease, hypertension, diabetes mellitus,
hyperlipidemia, gallbladder disease, obstetrical
complications, pulmonary abnormalities, endocrine-
related neoplasms, and accelerated degenerative
joint disease.1'9
The use of very low-
calorie diets (VLCDs), less
The authors are affiliated with
the Metabolic and Nutrition Ser-
vice, Newark Beth Israel Medical
Center, Newark. Requests for re-
prints may be addressed to Dr.
Kirschner (photo), director of
medicine, Newark Beth Israel
Medical Center, 201 Lyons Av-
enue, Newark, NJ 07112.
than 800 K cal/day, has introduced a new modality
for achieving major weight loss. Success rates of 40
or more pounds of weight loss have been reported at
60 to 80 percent by several VLCD programs.1012 The
early use of VLCDs was tainted by the rampant use
of low-quality liquid protein supplements that were
widely advertised and injudiciously used. The resul-
tant negative publicity of the VLCD approach was
highlighted in the critical article, “Liquid Protein
Mayhem”; Van Itallie condemned the unsupervised
commercialism in the field and called for the medi-
cal community to take control of the weight loss
effort in a responsible manner.13
Despite the “liquid protein mayhem” of the 1970s,
a scientific database demonstrated that high-quality
VLCDs, appropriately supervised by knowledgeable
physicians, were effective methods of achieving sig-
nificant and safe weight loss. New generation protein
supplements were developed with greater biologic
value precluding most of the complications of earlier
preparations.1416 Specifically, the newer generation
VLCDs were not associated with cardiac ab-
normalities after careful prospective monitoring.16
The medical community gradually began to accept
the use of VLCDs as a bonafide method for achieving
major weight loss.
On November 15, 1988, the celebrated television
VOL. 87— NUMBER 11 NOVEMBER 1990
901
personality Oprah Winfrey announced to her au-
dience that, she lost 67 pounds by participating in
a medically supervised VLCD program using Op-
tifast®. This dramatic media event immediately
provoked a new frenzy of public interest in the use
of VLCDs. Programs in existence at that time were
flooded with calls and many could not, nor did they
want to, handle the new volume of patients wanting
the “quick fix.” In the aftermath of the Oprah Win-
frey event, a consumer-driven interest in VLCDs
spawned a new generation of commercial ventures
into the weight loss field. These ventures took the
form of franchised commercial weight loss centers
promoted by major national advertising efforts, de-
emphasizing the medical aspect of weight loss; pow-
dered protein supplements available at super-
markets with no medical monitoring; and copycat
protein supplements marketed to private physicians
to dispense from office practices. This new wave of
commercialism of VLCDs again has sensationalized
weight loss and de-emphasized the role of carefully
supervised programs.
The current state of weight loss again has become
chaotic, provoking warnings of severe consequences
by the scientific community as well as provoking
congressional inquiries.17 In this current era of “may-
hem II,” serious physicians interested in rec-
ommending patients for major weight loss are in a
quandary as to where and to whom they can refer
obese patients for safe and effective weight loss.
THE OPTIFAST® MODEL
In view of the urgent health hazard presented by
widespread obesity in our New Jersey community,
we developed an outpatient VLCD program in 1976
fashioned after the method of Genuth and Vertes.10
This approach called for withdrawal from food and
substitution with protein formula of high biologic
value. We used the protein supplement based on the
Genuth formula, Optifast®, prepared by Delmark
Pharmaceutical Co. and then by Sandoz Nutrition.
During the initial years (1976 to 1980), patients re-
ceived a 45 g protein supplement of 300 K cal/day.
Since 1980, the manufacturer uses a higher protein
formulation consisting of 70 g protein from
pasteurized egg whites, calcium caseinate, and non-
fat dry milk sources (420 K cal/day). The Optifast®
supplement contains 100 percent of the recommend-
ed daily allowance of known vitamins and trace
metals as well as 1,900 mg potassium, 30 g carbo-
hydrate, and 2 g fat. Optifast® is taken five times
daily, along with 64 oz fluid and a fiber supplement.
Supplemental use of 20 meq K+ has been limited
to those patients with a history of diuretic use.
After attending a free orientation lecture, patients
are scheduled for an initial medical evaluation.
Much attention is paid to the presence of coexisting
medical illnesses and patients are evaluated careful-
ly for their ability to participate in the program.
With increasing experience, we have found that
many illnesses of great concern initially can be
handled readily during weight loss. In particular,
type II diabetes mellitus generally can be handled
on an outpatient department basis, with insulin
withdrawal guided by C-peptide responses. Hyper- .
Table 1. Contraindicating medical
conditions and illnesses.
Medical Contraindications for
Very Low Calorie Diets
1. Recent myocardial infarction
(less than three months)
2. Recent cerebrovascular accident
3. Pregnancy and nursing
4. Type I diabetes mellitus
5. Active infectious diseases (TBC and AIDS)
6. Previous history of anorexia nervosa
Relative Contraindicating Conditions
1. High-dose steroids, asthma, lupus
2. Adolescence, preadolescence
3. Previous addictive illnesses, bulimia
4. Dialysis dependence
tension is monitored and most if not all anti-
hypertensive medication can be withdrawn after a
few weeks. Contraindicating medical conditions and
relative contraindicating medical illnesses are pre-
sented in Table 1.
Following initial physical examination, basal
chem-zyme profiles, thyroid functions, and elec- |!
trocardiogram, patients begin the Optifast® regimen
on an outpatient basis. A patient returns for weekly
visits; at each visit, the patient is seen by the treat- 5
ing physician for medical evaluation and attends a
group behavior modification session. Complete
blood count and multiphasic chemistry profiles are
obtained every other week to monitor changes in uric
acid, electrolytes, blood sugar, liver function tests,
and lipid profiles. Repeat electrocardiograms are
performed after three to four months or as indicated
when ectopy is heard, or if the patient complains of
palpitations.
Our first year’s experience with Optifast® ob-
served initial first week weight loss 11.0 ± 3.0
pounds in men and 7.7 ±2.1 pounds in women.
Subsequent weight loss proceeded at the average
weekly rate of 4.2 ±1.0 pounds in men and 3.0 ±
1.0 pounds in women.11 Our eight-year experience
with 4,026 patients demonstrated similar rates of
weight loss (Figure).12 A 1989 survey demonstrated
similar rates of weight loss.
We have been impressed by the improvement of
coexisting medical illnesses, as the results of weight
902
NEW JERSEY MEDICINE
loss. The ameliorative effects of weight loss on hy-
pertension, diabetes mellitus, hypertriglyceridemia,
and hypercholesterolemia have been extended to in-
clude an ameliorative effect on obstructive sleep
apnea."12 Other groups have reported similar im-
provement in pre-existing medical illnesses after
VLCD-induced weight loss.1718 Complications re-
main minimal with no evidence that modern-day
VLCDs are associated with cardiac arrhythmias or
cardiac toxicity.14 16 Although there is current con-
cern that VLCDs provoke cholelithiasis, we en-
counter only five to ten cases a year (less than 1
percent) of clinically significant cholelithiasis/
cholecystitis and these occur uniformly during the
refeeding phase. Table 2 lists effects of weight loss
on coexisting medical problems.
COMPONENTS OF A RESPONSIBLE PROGRAM
Responsible and knowledgeable physician leader-
ship. Modern-day VLCDs are associated with few
and manageable medical problems. Nonetheless, a
modified fast is a stress stimulus that alters body
metabolism changes, hormone production, and drug
clearance and often alters coexisting medical prob-
lems. Physicians caring for patients undergoing
VLCDs should have thorough training in areas of
clinical nutrition as well as knowledge of changes in
body composition, energy metabolism, and cardiac
function during calorie restriction. Ideally, physi-
cians with backgrounds in endocrine and metabolic
diseases are best trained in these areas, although
other physicians dedicated to acquiring this infor-
mation also are suited. Physician directors of VLCDs
should be readily identifiable and available to pa-
tients. A responsible program should have a call-
back system and emergency call system so patients
have access to physician advice.
Behavior modification sessions. Group behavior
modification sessions are an important component
of a responsible weight loss program. Previous data
clearly demonstrate that weight loss is improved by
adjunctive use of behavior modification efforts.18'20
Patient counsellors trained in group psycho-
dynamics and behavior modification methods
provide ongoing education and group support. In our
experience, the weekly 45-minute group session is
equally important, if not more so, than the 15-
minute medical check. Dietitians are an important
part of the treatment team providing nutritional
advice, lectures, and assistance to patients during
periods of life events. Exercise physiologists, clinical
psychologists, and psychiatrists provide an ad-
Table 2. Effect of weight loss on
Table 3. Responsible weight loss programs
coexisting medical problems.
in New Jersey.
1. Medical Problems Improved by Weight Loss
Optifast® Programs
Hypertension
Metabolic & Nutrition Service-Newark
Diabetes mellitus (type II)
Metabolic & Nutrition Service-Paramus
Hypercholesterolemia
Metabolic & Nutrition Service-Wayne
Hypertriglyceridemia
Metabolic & Nutrition Service-Roseland
Menstrual irregularities and infertility
Metabolic & Nutrition Service-Princeton
Sleep apnea
Doctors On Duty-Union
Pickwickian syndrome
St. Mary’s Hospital-Hoboken
COPD
Raritan Bay Medical Center-Perth Amboy
Lumbosacral disc syndrome
Riverview Medical Center-Red Bank
Osteoarthritis— weight-bearing joints
Somerset Medical Center-Somerville
Gastritis, peptic ulcer disease,
The Medical Center at Princeton-Princeton
irritable bowel syndrome
St. Francis Medical Center-Trenton
Newton Memorial Hospital-Newton
3. Medical Problems Generally Unchanged
by Weight Loss
HMR Programs
Cardiac arrhythmias, under control
Pascack Valley Hospital-Westwood
Psychiatric disorders
Healthfast-Hackensack
Hypohyperthyroidism
The General Hospital Center at Passaic-Passaic
Hirsutism, PCO
Immedicenter-Bloomfield
Chronic renal disease
Alliance For Weight Management-Morristown
Lupus, scleroderma
Overlook Center for Weight Management-Summit
Sarcoidosis
Healthstyles Weight Management-Long Branch
Cancer, in remission
Medford Health Center-Medford
Atlantic City Medical Center-Atlantic City
2. Medical Problems that may be
Others
Exacerbated by Weight Loss
Gout
United Weight Control-Roseland
Cholelithiasis
New Directions Program-Hackensack
Addictive disorders
New Directions Program-Hackettstown
903
HHHE
VOL. 87— NUMBER 11 NOVEMBER 1990
re
ditional support network for patients going through
the program.
Maintenance program. Patients need long-term
guidance and relapse prevention during the process
of refeeding.12’ 1921 Pre-existing eating patterns need
to be altered and problems associated with refeeding
need to be carefully avoided. Supervision by dieti-
tians guide patients through the realimentation pro-
cess. This phase of the weight loss program clearly
is the most strenuous and difficult component.
Overall program. An effective weight loss program
goes beyond the narrow limits of a doctor-patient
relationship; it is a programmatic activity where the
patient receives multiple levels of support and
education during the weight loss effort.
PROGRAMS IN NEW JERSEY
Although our own program used the protein sup-
plement, Optifast®, the new generation protein
amino acid supplements are of high biologic caliber,
and differences between one supplement versus
another are less important today than a generation
ago. The components of a responsible weight loss
program include the use of a high-quality protein
supplement and high-quality medical leadership,
AVERAGE RATES OF WEIGHT LOSS
Figure. Average rates of weight loss during supplemented fast-
ing program using Optifast®. After the initial week, men lost at
a rate of 4.6 Ib/wk, women averaged 3.1 Ib/wk. Vertical bars
represent standard errors. (Reproduced by permission, Int J
Obesity)
behavioral counselling, group sessions, dietitian
availability, and an active maintenance program.
Responsible weight loss programs available to resi-
dents of New Jersey are presented in Table 3. ■
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1. Bray GA, Davidson MB, Drenick EJ: Obesity: A
serious symptom. Ann Intern Med 77:779-795, 1972.
2. Bray GA: Major Problems in Internal Medicine.
Philadelphia, PA, WB Saunders, 1976.
3. Kopelman PG: Clinical complications of obesity.
Clinics Endocrinol Metab 13:613, 634, 1985.
4. Van Itallie TB: Health implications of overweight
and obesity in the United States. Ann Intern Med
103:983-988, 1985.
5. NIH Consensus Development: Health implications of
obesity. Ann Intern Med 103:1073-1077. 1985.
6. Hubert HB, Feinlieb M, McNamara PM, Castelli
WP: Obesity as an independent risk factor for
cardiovascular disease: A 26-year followup of participants
in the Framingham heart study. Circulation 67:968-977,
1983.
7. Krai SG: Morbid obesity and related health risks.
Ann Intern Med 103:1043-1047, 1985.
8. Drenick EJ, Bale GS, Seltzer F, Johnson DS: Ex-
cessive mortality and causes of death in morbidly obese
men. JAMA 243:443-445, 1980.
9. Kirschner MA, Schneider G, Ertel NH, Worton E:
Obesity, androgens, and cancer risk. Cancer Res
42:3281-3285, 1982.
10. Genuth SM, Castro H, Vertes V: Weight reduction
in obesity by outpatient semi-starvation. JAMA
230:987-991, 1974.
11. Kirschner MA, Schneider G, Ertel NH, Cortes G:
Supplemental starvation: A successful method for control
of major obesity. J Med Soc NJ 76:175-179, 1979.
12. Kirschner MA, Schneider G, Ertel NH, Gorman J:
An eight-year experience with a very low-calorie formula
diet for control of major obesity. Intern J Obesity 12:69-80,
1988.
13. Van Itallie TB: Liquid protein mayhem. JAMA
240:144, 1978.
14. Amatruda JM, Biddle TL, Patton ML: Vigorous
supplementation of a hypo-caloric diet prevents cardiac
arrhythmias and mineral depletion. Am J Med
74:1016-1022, 1983.
15. Lockwood DH, Biddle TL, Amatruda JM: Cardiac
arrhythmias with collagen-based diets but not with more
complete diets, in Blackburn GL, Bray GA, Management
of Obesity by Severe Calorie Restriction. Littleton, MA,
PSG Publishing Co., 1985, pp. 205-213.
16. Frank S, Colliver JA, Frank A, Verhulst MA: Elec-
trocardiographic changes associated with weight reduc-
tion. Int J Obesity 11:27, 1987.
17. Wadden TA, Van Itallie TB, Blackburn GL: Re-
sponsible and irresponsible use of very low-calorie diets in
the treatment of obesity. JAMA 263:83-85, 1990.
18. Palgi A, Read I, Greenberg L, et ah: Multi-
disciplinary treatment of obesity with a protein-sparing
modified fast: Results in 668 outpatients. Am J Pub
Health 75:1190, 1985.
19. Kanders BS, Blackburn GL, Lavin P, Norton D:
Weight loss outcome and health benefits associated with
the Optifast" program in the treatment of obesity. Int J
Obesity 13:131, 134, 1989.
20. Wadden TA, Stunkard AJ, Liebschutz J: Three-
year followup of the treatment of obesity by very low-
calorie diet, behavior therapy, and their combination. J
Consult Clin Psychol 86:925-928, 1988.
21. Perri MG, McAllister DA, Grange JJ, et ah: Effects
of four maintenance programs on the long-term manage-
ment of obesity. J Consult Clin Psychol 56:529-534, 1988.
22. Manson JE, Colditz GA, Stampfer MJ, et ah: A
prospective study of obesity and risk of coronary heart
disease in women. N Engl J Med 322:882-889, 1990.
904
NEW JERSEY MEDICINE
Research in
Sleep Medicine
JEFFREY NAHMIAS, MD
MONROE KARETZKY, MD
The field of sleep disorders medicine has
matured into a respected area of medical
science over the past two decades as basic
and clinical research have defined the normal physi-
ology of sleep and classified the clinical disorders of
the sleep-wake cycle into a specific nosology.14
One major area of research involves the obstruc-
tive sleep apnea (OSA) syndrome. OSA is charac-
terized by periods of repetitive upper airway collapse
during sleep, causing asphyxiation. A myriad of neu-
rogenic responses results in an eventual arousal as-
sociated with restoration of a patent upper airway
and resumption of normal breathing, until the next
apneic event. The typical apneic episode, by defi-
nition, will last greater than 10 seconds and up to
120 seconds (average 22 seconds) with long-term se-
quelae such as systemic and pulmonary hyper-
tension, cor pulmonale, cardiac arrhythmias, and
death. Due to repetitive arousals, these patients
have an inadequate total amount and quality of
sleep, resulting in excessive daytime sleepiness
(EDS), the most frequent complaint of patients at
a sleep center.
DIAGNOSIS OF OSA
Sleep centers continue
to search for a “screening
tool” to supplement the
history in order to de-
Dr. Karetzky (photo) and Dr.
Nahmias are affiliated with the
Newark Beth Israel Sleep Dis-
orders Center. Requests for re-
prints may be addressed to Dr.
Nahmias, Newark Beth Israel
Medical Center, 201 Lyons Av-
enue, Newark, NJ 07112.
termine which patients should undergo all-night
polysomnographic testing, as well as an indicator for
assessing the response to therapy. Flow volume
curves (VVC) have been proposed to have such a
screening value by determining the predisposition of
the upper airway to obstruction.5 Other means of
evaluating the upper airway such as cephalometric
x-rays,6 computerized tomography,7 and fiberoptic
visualization8 are primarily used for determining
both the necessity and feasibility of surgical inter-
vention.
We evaluated the effect of the sleeping position,
i.e. supine posture, in enhancing the usefulness of
the spirometric maneuver as a screening test for
polysomnography. In our study of 48 patients with
and without OSA, we examined the sensitivity and
specificity of sawtoothing, maximal midexpiratory
flow rate ratio (MMFRR) and flattening of the in-
spiratory limb of VVC performed in both the upright
and supine positions. Each patient also had an all-
night polysomnogram and arterial blood gas de-
termination. The combination of an upright and
supine VVC yielded a significantly higher sensitivity
(89.3 percent) than upright testing alone (67.9 per-
cent), when all criteria were examined. Although the
sensitivity of sawtoothing alone in predicting OSA
was low, its specificity as initially reported was high
at 90 percent.
Our data revealed that by utilizing simple pos-
tural spirometric testing in patients who have a
clinical history equivocal for OSA, patients who
would have a very low yield on all-night poly-
somnography can be screened out. Testing, however,
would be indicated in those patients with multiple
VVC criteria present (especially sawtoothing) who
were apt to have a significant number of disordered
VOL. 87— NUMBER 11 NOVEMBER 1990
907
[0.028 (JKIBW) + 0.015 (A+HI) - 0.071 (Sa02 NADIR) + 8.69 = CPAP]
Figure 1. Comparison of predicted positive pressure versus
actual pressure required to maintain airway patency. The mul-
tiple regression analysis equation for predicted values is shown
below the graph. IBW, ideal body weight; A + HI, number of
apneas and hyponeas per hour; Sa02 nadir, low point nocturnal
saturation.
breathing events (DBE) during sleep. In addition,
with weight loss we also have demonstrated the util-
ity of VVC by monitoring its return to normal as a
means of determining when the patient should be
retested with polysomnography.9
Some laboratories utilize a three-hour nap study
as a screening test for OSA. The problem with per-
forming nap studies is that short recording times and
low percentage of rapid eye movement (REM) sleep
lead to misdiagnosis or a significant underestimation
of the number of DBE in OSA.10
EFFECTS OF OSA
The obesity-hypoventilation syndrome is charac-
terized by apneas and the clinical findings of right
ventricular dysfunction as well. The incidence of
cardiac impairment is felt to be small and usually
only with associated obstructive lung disease. Utiliz-
ing nuclear ventriculography, we have shown a much
higher incidence of right ventricular dysfunction and
a strong suggestion of associated left ventricular dys-
function as well.13 This circumstantial evidence for
ischemic cardiopathy and its treatment is being
pursued in candidates for coronary surgery and
pacemaker placement.
TREATMENT OF OSA-NCPAP
Nasal continuous positive airway pressure
(NCPAP) is the most widely prescribed treatment
modality for patients with OSA. NCPAP consists of
a tight fitting nasal mask connected by flexible tub-
ing to an air flow generator. The air pressure is
transmitted to the nasal and oropharynx, acting as
a pneumatic splint and preserving airway integrity.
NCPAP is successful in virtually 100 percent of pa-
tients and tolerated by 66 to 75 percent of patients.
Typically, the patient who has been diagnosed as
having OSA will spend a second night of poly-
Figure 2. Treatment of OSA utilizing a nasopharyngeal tube ’/z
cm above the epiglottis.
somnographic study in a sleep center while the tech-
nician slowly increases the pressure, until the dis-
ordered breathing events are eliminated. The pa-
tient then is prescribed a NCPAP home unit at that
pressure.
There often is a delay between night studies of up
to three weeks, leaving the severely apneic patient
unprotected from the potential cerebral and
cardiovascular catastrophes and daytime som-
nolence. To expedite treatment of the severe apneic,
we performed an analysis of 24 patients who under-
went NCPAP testing to determine which patient
characteristics and sleep parameters could be used
to predict the pressure required to eliminate the
apneic episodes in order to initiate effective therapy
without delay." Utilizing multiple regression
analysis, it was determined that percentage of ideal
body weight, Sa02 nadir and A + HI, were most close-
ly correlated with required NCPAP (Figure 1).
Although NCPAP is the treatment of choice for
patients with OSA, 25 to 35 percent of patients can-
not tolerate NCPAP and in a small percentage of
patients, NCPAP does not succesfully eliminate the
apneic events. For these patients, we have in-
troduced an alternative treatment modality for long-
term management utilizing an uncuffed pediatric
(3. 0-4.0 mm) nasopharyngeal (NP) tube. This tube
is passed through either nare, nasopharynx, and or-
opharynx, with its distal opening resting in the
hypopharynx V2 cm above the epiglottis (Figure 2).
Local anesthesia (4 percent xylocaine spray) is self-
applied to the nasal mucosa. In a study of 44 pa-
tients fitted with the NP tube, 24 patients were
restudied with the nasal catheter in place.12 The NP
tube was successful in two-thirds of these patients.
The NP tube was found to be an effective alternative
treatment for patients with OSA who could not tol-
908
NEW JERSEY MEDICINE
. : ■ " ' - • ■ ■ ,
> :
# criteria
FIF50
I SIT BB SUPINE □ SIT ♦ SUPINE
Figure 3. Comparison of upper airway obstruction criteria pre-
and postweight loss. VEO = variable extrathoracic obstruction
(flattening of inspiratory limb); SW = sawtoothing; FEF50/FIF50
= MMFRR; ALL = combination of all three criteria; SIT = sitting
position.
erate NCPAP. It is most successful in patients who
have mild to moderate OSA, i.e. A + HI < 60, and
for those patients who are not morbidly obese. Some
patients reserve the use of the NP tube for travel,
preferring not to take along the compressor required
for NCPAP. Another major indication for utilization
of the NP tube has been during emergent situations
in the intensive care unit. Patients with the obesity-
hypoventilation syndrome presenting with malig-
nant dysrhythmias, accelerated hypertension, CVA,
respiratory failure, or myocardial infarction with the
threat of prolonged apneic episodes, respond to a
large bore (7.0 mm) NP tube with immediate resol-
ution of their upper airway collapse and resulting
asphyxiation.
Treatment of OSA usually involves a combination
of weight loss and the application of positive airway
pressure by NCPAP. The beneficial effect of weight
loss on the severity of apnea has been docu-
mented;1417 however, the numbers of patients in
these studies are small and the beneficial effects on
awake gas exchange, arterial blood gases (ABG), and
functional upper airway diameter have not been
documented.
We examined the effect of weight loss on these
parameters, as well as on the DBE.9 Eighteen pa-
tients underwent all-night polysomnography fol-
lowed by supine ABGs and maximal effort flow vol-
ume curves, pre- and post-weight loss. Their mean
body weight decreased from 283 pounds to 227
pounds representing a decrease in mean percentage
ideal body weight from 169 to 136 percent. The im-
provement in nocturnal oxygen saturation in part
was attributable to an increased awake Pa02 as well
as a decrease in the severity of their OSA. The rest-
ing alveolar ventilation increased as well as reflected
by the PaC02 that decreased from 49.6 to 38.9 mm
Hg. All 6 patients with awake alveolar hypoventila-
tion showed normalizaton of PaC02 after weight loss.
Patients no longer were polycythemic with the mean
Hb concentration falling from 15.8 to 13.9 gm/dL
after weight loss.
Flow volume curves were useful in detecting im-
provements in DBE indices with a significant de-
crease in the number of upper airway obstruction
criteria present after weight loss (Figure 3).
DISORDERS OF EXCESSIVE SOMNOLENCE
AND IDIOPATHIC CNS HYPERSOMNOLENCE
The prototype clinical entity of the group of dis-
orders of excessive somnolence (DOES) is the
narcolepsy-cataplexy syndrome consisting of the
tetrad of symptoms including irresistible sleep at-
tacks, cataplectic episodes, sleep paralysis, and hyp-
nogogic hallucinations.18 Cataplexy is the sudden
loss of motor tone resulting in partial or complete
skeletal muscle paralysis. Emotional stimuli, such
as laughter, anger, or elation are common precipi-
tating events causing the patient to slump to the
floor or, cause drooping of the jaw with inability to
speak and subtle weakness of the neck, arms, or legs.
This atonia occurs without the loss of consciousness.
Sleep paralysis consists of flaccid paralysis of the
skeletal muscles upon awakening from sleep, while
hypnogogic hallucinations are vivid, usually fright-
ening visual and/or auditory hallucinations occur-
ring at sleep onset.
Narcolepsy is mainly a disturbance of REM sleep,
such that the “REM-on” cells are activated during
periods of wakefulness provoking irresistible sleep
attacks and the ancillary symptoms. However, it is
also a disorder of non-REM sleep as well.
Idiopathic central nervous system hyper-
somnolence (ICNSH), another disorder of excessive
somnolence, does not appear to be a REM-related
disorder as there are no associated ancillary symp-
toms such as cataplexy. The pathognomonic sleep
onset REM (SOREM) periods of narcolepsy are not
observed during the multiple sleep latency test
(MSLT). MSLT consists of a series of naps, separ-
ated by two hours in which the time it takes the
patient to fall asleep, sleep latency (SL), is
monitored. It provides for both an objective measure
of daytime sleepiness and for the determination of
the presence of SOREM periods. Sometimes referred
to as non-REM narcolepsy, ICNSH produces quite
severe daytime sleepiness with little relief attained
from daytime naps (narcoleptics classically have re-
freshing naps).
To further assess the clinical and poly-
somnographic features of these two related dis-
orders, we reported a retrospective study of 33 pa-
tients.19 Twenty-four patients with narcolepsy and 9
patients with idiopathic central nervous system
(CNS) hypersomnolence were compared. Patients
with narcolepsy were both older at the time of
diagnosis and had a longer duration of symptoms
VOL. 87— NUMBER 11 NOVEMBER 1990
909
prior to a definitive diagnosis.
Nocturnal sleep studies confirmed both the
fragmented sleep of narcoleptics and the normal
sleep of idiopathic CNS patients. The idiopathic
CNS hypersomnolence patients had a higher sleep
efficiency of 89.9 percent as compared to 79.5 per-
cent in the narcoleptic group. Of note, the percent
stage three and four (deep) sleep was high normal
in the idiopathic CNS hypersomnolence group (19.6
percent) and significantly lower in the narcolepsy
patients (5.0 percent). As expected, the narcoleptic
patients had a shorter REM latency of 34.2 min
versus 92.9 min for the idiopathic CNS hyper-
somnolence group. The idiopathic CNS hyper-
somnolence group was equally “sleepy” as the
narcoleptics as assessed by the MSLT.
Patients with narcolepsy tend to have a more
fragmented night’s sleep and are older at time of
diagnosis, while patients with idiopathic CNS hy-
persomnolence have normal sleep architecture and
sleep efficiency. Both groups are equally hyper-
somnolent. We currently are examining the psycho-
logical profile, memory, and treatment response in
patients with narcolepsy and idiopathic CNS hyper-
somnolence.
DISORDERS OF THE SLEEP-WAKE SCHEDULE
Some patients suffer from a persistent sleep-wake
schedule disorder such that their biological clock is
“out-of-synchrony” with the normal clock time.
These patients cannot fall asleep until the early
morning hours and then will sleep a normal eight
hours until the late morning or early afternoon and
awaken refreshed. However, if they are aroused in
the early morning to get ready for work or school,
the patient will become belligerent, often demon-
strating “sleep drunkenness,” and will remain som-
nolent throughout the morning hours. These pa-
tients are suffering from delayed sleep phase syn-
drome and they have difficulty in attending school
or maintaining their job, as chronic tardiness, morn-
ing sleep attacks, and absenteeism interfere with
these responsibilities. In the past, the major
chronobiologic treatment modality was phase delay,
whereby the patient’s bedtime and morning awak-
ening would be altered by three hours each day until
the good night time was normalized. Our use of light
therapy has been included in the treatment regimen
for these patients. By utilizing intense (10,000 lux)
light at the proper time in the morning a patient’s
sleep cycle can be slowly advanced to a more ap-
propriate schedule which is societal synchronized.
CONCLUSION
Sleep disorders medicine is a rapidly expanding
field that has exhibited a logarithmic growth curve
in the past two decades. The diversity of syndromes
and combinations of disorders that may coexist
make it imperative that a complete evaluation be
performed on each patient. ■
REFERENCES
1. Dement W, Guilleminault C: Diagnostic classi-
fication of sleep disorders. Sleep 2:21-1211, 1979.
2. Bremer F: Ceveau isole et physiologie du sonmeil. CR
Soc Biol 118:1235-1241, 1935.
3. Aserinsty E, Kleitman N: Regularly occurring
periods of eye motility and concomitant phenomena dur-
ing sleep. Science 118:273-274, 1953.
4. Rechtschaffen A, Kales A: A manual of standardized
terminology, techniques, and scoring system for sleep
stages of human subjects. Publication 204, U.S. Dept, of
Health, Education and Welfare, Public Health Service,
1968.
5. Shore ET, Millman, RP: Abnormalities in the flow-
volume loop in obstructive sleep apnea sitting and supine.
Thorax 39:775-779, 1984.
6. Riley RW, Guilleminault C, Herran J, Powell N:
Cephalometric analysis and flow-volume loops in obstruc-
tive sleep apnea. Sleep 6:303-311, 1983.
7. Haponick, EF, Smith PL, Bohlman ME, et al.: Com-
puterized tomography in obstructive sleep apnea. Correla-
tion of airway size with physiology during sleep and
wakefulness. Am Rev Resp Div 127:221-226, 1983.
8. Browiecki B, Pollack CP, Weitzman E: Fiberoptic
study of the pharyngeal airway during sleep in patients
with hypersomnia sleep apnea syndrome. Laryngoscope
88:1310-1313, 1978.
9. Nahmias J, Fourre J, Karetzky M: Effect of weight
loss on the upright and supine flow-volume curves, arterial
blood gases and disordered breathing events in patients
with obstructive sleep apnea. Chest 92:675, 1987.
10. Fourre J, Scoles V, Nahmias J, Karetzky M: The
use of nap studies in the diagnosis of obstructive sleep
apnea. Sleep Res 15:122, 1986.
11. Ramos R, Nahmias J, Karetzky M: Determinants
of the magnitude of NCPAP in obstructive sleep apnea.
Sleep Res 18:291, 1989.
12. Nahmias J, Karetzky M: Treatment of the obstruc-
tive sleep apnea syndrome using a nasopharyngeal tube.
Chest 94:1142-1147, 1988.
13. Nahmias JS, Karetzky M: Assessment of risk fac-
tors for right ventricular failure in patients with the ob-
structive sleep apnea syndrome. Chest 94:615, 1988.
14. Smith PL, Gold AR, Meyers PA, et ah: Weight loss
in mildly to moderately obese patients with obstructive
sleep apnea. Ann Intern Med 103:850-855, 1985.
15. Browman CP, Sampson MG, Yolles SF, et ah: Ob-
structive sleep apnea and body weight. Chest 85:435-436,
1984.
16. Harman EM, Wynn JW, Block, AJ: The effect of
weight loss on oxygen desaturation in morbidly obese men.
Chest 82:291-294, 1982.
17. Sugerman HJ, Baron P, Fairman RP, et al.:
Hemodynamic dysfunction in obesity hypoventilation
syndrome and the effects of treatment with surgically in-
duced weight loss. Ann Surg 207:604-612, 1988.
18. Nahmias J, Karetzky M: Current concepts in
narcolepsy. NJ MED 86:617-622, 1989.
910
NEW JERSEY MEDICINE
in-1
in
'< '
3D-
m-
32-
T-
xl
Monoclonal Antibody
Therapy of Cancer
u-
th
::
1 v
I! DAVID M. GOLDENBERG, ScD, MD
ROBERT M. SHARKEY, PhD
HILDEGARD GOLDENBERG, MD
THOMAS C. HALL, MD
^ ^ he last decade has witnessed an un-
precedented expansion of new knowledge on
JL the complex interaction of host regulatory
systems, including the immune system, and the con-
trol of cell growth and function. This has resulted
in a new technology devoted to biologies acting as
- stimulators or inhibitors of specialized cellular func-
tions and control mechanisms, and a diverse array
I of biological response modifiers (BRMs). A particu-
lar opportunity has been the application of BRMs
to cancer therapy. Interferons were the first of these
used in modern biotherapy, followed by inter-
leukin-2, as well as various cytokines, such as other
interleukins and growth factors, e.g. G-CSF, GM-
CSF.1 BRMs may exert either direct antitumor ef-
fects, work in concert with other host effector mech-
anisms, or stimulate the proliferation of normal
hematopoietic cells affected by chemotherapy or
radiation therapy. There also has been a recent re-
surgence of interest in tumor vaccines.2
Antibodies developed against cancer cells have
been used in a number of ways to halt the growth
of neoplasms, or even to af-
Dr. Goldenberg (photo) and the
other authors are affiliated with
the Center for Molecular Medi-
cine and Immunology, Newark.
This work has been supported in
part by USPHS grant CA 39841
from the NIH. Requests for re-
prints may be addressed to Dr.
Goldenberg, President, Center
for Molecular Medicine and Im-
munology, 1 Bruce Street, New-
ark, NJ 07103.
SUMATHI MURTHY, MD
DANIEL O. IZON, MD
PEDRO GASCON, MD
LAWRENCE C. SWAYNE, MD
feet tumor regression. The development of mono-
clonal antibody (MAb) technology by hybridization
methods has resulted in a renewed interest in the use
of anticancer antibodies in cancer therapy.3 These
MAbs can act by at least four mechanisms: activa-
tion of components or effector cells of the immune
system, such as triggering complement- or antibody-
dependent cytotoxicity; interference with growth or
differentiation by binding to the tumor cells, such
as to growth factors or receptors on the tumor cell
surface; active immunization by the MAb, such as
by an anti-idiotype vaccine; and delivery of toxic
agents, such as drugs, toxins, and radionuclides.
MAbs also can be used to enhance the activities of
other BRMs, such as interferon and interleukin-2,
that have independent antitumor actions. Further,
MAbs have been used to direct effector cells to
tumor by being conjugated to antibodies or factors
specific for these effector cells.
Specific passive immunotherapy of cancer by the
injection of naked xenogeneic and allogeneic anti-
sera made against cancer in a variety of animal hosts
has been attempted for about 100 years, and has
resulted in only anecdotal examples of response
often accompanied with severe toxicity.4'7 These
antibodies generally were very impure and poorly
characterized, thus preventing duplication in con-
trolled trials. With the advent of MAbs, where large-
scale production of uniform and identical antibodies
could be generated, a more systematic approach to
specific passive immunotherapy could be under-
taken. The majority of such studies focused on the
treatment of hematological neoplasms, and has in-
VOL. 87— NUMBER 11 NOVEMBER 1990
913
volved more than 25 clinical trials in which over 135
patients have been treated with unconjugated
MAb.8 This study showed a complete remission rate
of 5 percent, a partial remission rate of 16 percent,
and 17 percent minor responses.8 Such regressions,
for the most part, were of short duration. Likewise,
a variety of solid human tumors have been treated
with MAbs, including melanoma,9'11 neuroblas-
toma," and colon carcinoma.12'14 Since the majority
of patients included in these studies were heavily
pretreated and had advanced disease, it is likely that
their immune systems were too compromised to re-
spond to the immunotherapy. Nonetheless, MAbs
given alone have shown definite antitumor effects in
hematological and solid malignancies, and it is like-
ly that methods to improve their effects, such as in
a combination with various cytokines that activate
different immune functions, will be developed.
Binding
IgG
F(ab’)2
Fab’
Mouse Human
\ 1=1— 1=1 vL
Single-chain Antibody
Chimeric Antibody
Figure 1. Schematic representation of immunoglobulin G,
F(ab')2 and Fab’ fragments, chimeric antibody, and single-chain
antibody forms.
In general, the overall results of naked MAb ther-
apy have been disappointing, but they have ex-
panded our knowledge of how such antibodies can
exert their antitumor effects. As mentioned earlier,
the three principal mechanisms are direct inhibition
of cell growth by binding to cell surfaces; cooper-
ating with host effector mechanisms to institute a
lysis of tumor cells coated with antibody; and alter-
ing the host’s immune system to initiate tumor re-
jection. These approaches have encountered a
number of problems, many of which have limited
further progress in the use of MAbs: 1) the presence
of free circulating antigen that can complex with the
injected MAb; 2) modulation or disappearance of
the target antigen from the tumor cell; 3) heter-
ogeneity of antigen expression; 4) the relatively low
targeting and uptake of the injected MAb; and 5)
the immunogenicity of murine MAbs. One immedi-
ate solution to some of these problems is to increase
the potency of the MAb therapeutic by making the
MAb a delivery vehicle for drugs, toxins, or radio-
active agents. This review will focus on this alterna-
tive approach, the targeting of toxic agents to
cancer, thus rekindling the concept expressed by
Paul Ehrlich at the turn of the century:
Zauberkugeln (magic bullets) as “bodies which pos-
sess a particular affinity for a certain organ” to carry
therapeutic agents.18 However, as attractive as this
concept has been, it still is beset with four major
limitations. First, MAbs truly specific for cancer
have not been identified yet. Second, it is rare to find
a MAb that is restricted even to a single cell type,
such as a bronchial squamous cell cancer or a colonic
adenocarcinoma. Such MAbs sometimes are reac-
tive with many tumor types within a system, but
more frequently reactive with many different cell
types, as pancarcinoma antibodies. The most
reknowned of these are carcinoembryonic antigen
(CEA) antibodies,16 that are reactive with
gastrointestinal adenocarcinoma, squamous cell
cancers, and adenocarcinoma of the lung, some
mammary carcinomas, mucinous adenocarcinomas
of the ovary, squamous cell carcinoma of the uterine
cervix, and adenocarcinoma of the endometrium.17
A third limitation of MAbs as targeting agents for
a more specific cancer therapy is the relatively low
uptake in tumor: less than 0.01 percent to 0.001
percent of the injected dose usually accretes per
gram of tumor.18 The result is that only a small
portion of the injected dose of both antibody and
cytotoxic agent arrives at the tumor.
The fourth major limitation involves the predomi-
nant use of MAbs generated in mice. When injected
into humans who are not too immunocompromised,
antibodies against these foreign proteins, termed
human anti-mouse antibodies (HAMA), are formed,
and these complex to and interfere with the target-
ing antibody.1921 This also has been a problem in the
use of unconjugated MAbs, but in patients with
lymphoma, the HAMA response appears to be more
limited than in patients with solid tumors,
presumably because of a greater immunosuppressive
state in the former group.22,23
Despite these problems, impressive advances are
being made in the use of MAb conjugates for cancer
detection and therapy, and it appears that radio-
labeled MAbs will be the first MAb agents to be
added to the oncologist’s armamentarium. The uses
will be in the radioimmunodetection (RAID) and
radioimmunotherapy (RAIT) of cancer. RAID is the
914
NEW JERSEY MEDICINE
5^
■ i
Table 1.
Isotopes for antibody imaging.
■B -.Till'S^
t.:.T
Isotope
Half-Life
A-Energy
(keV)
Isotope Cost
per Study ($)
Image
Quality
Disadvantages
"mjc
6 h
140
<10
Excellent
Renal uptake
"'In
3 d
173, 247
75
Excellent
Liver and spleen uptake
1 23 1
13 h
159
180
Excellent
Availability
1311
8 d
364
13
Not Good
/3-emissions
Table 2. Indications for antibody imaging.
• Presurgical staging of extent of disease
• Postsurgical evaluation of residual disease
• Confirmation of viable tumor known by other methods
i • Disclosure of recurrence in a patient with a rising
tumor market titer in the blood
• Confirmation of tumor targeting of antibody to be
used for chemoimmunotherapy or radioimmuno-
therapy
use of radiolabeled antibodies to detect lesions by
external scintigraphy, whereas RAIT is the ex-
tension of these agents to targeted isotopic cancer
therapy.24 Both RAID and RAIT have been under
investigation for many years, predating the era of
e MAbs,25'27 but undoubtedly have had their most in-
~ tensive attention since the advent of MAbs.28'31
e
RADIOIMMUNODETECTION (RAID)
Most current radiological methods used to disclose
lesions depend upon anatomical changes. Antibody
targeting involves a functional test, since it requires
the production and presence of a target antigen
bound by the antibody. For example, fibrous tissue,
that could present a problem in computed tomo-
graphic interpretation of a postsurgical lesion,
should not accrete radioactive antibodies. However,
if a tumor lacks sufficient quantities of the target
antigen, the antibodies may fail to bind to the tumor
and deposit sufficient radioactivity to be detected by
the gamma camera. Therefore, there is an important
interaction between tumor and quantity of available
antigen, quantity of antibody and radioactivity de-
posited, site of tumor and organ involved, and the
scanning procedure. The two most important initial
considerations are the specificity of the target anti-
gen for cancer and the nature of the antibody used
for targeting. The currently known cancer antigens
are not restricted to cancer cells in terms of absolute
specificity. However, many antigens of different
chemical nature have been found to be increased in
cancers and sometimes shed in increased quantity
into the blood of patients with growing neoplasms.
These antigens can serve as targets for tumor-lo-
calizing antibodies, even when they are shed into the
circulation, where the administered antibodies can
form complexes. When an antibody targets to a
tumor antigen, it needs to have an uptake ratio of
about 2:1 to background for imaging, while a mini-
mal ratio of about 5:1 may suffice for therapy. The
satisfactory ratio for imaging depends in part upon
the scanning method used. Planar imaging may re-
quire a ratio of about 5:1, whereas single-photon
emission computed tomography (SPECT), that
slices through the body like a CT scanner, only de-
tecting emitted radiation, requires much lower
tumor/nontumor ratios, such as 2:1. 32 Thus, the
absolute uptake of antibody in tumor is not critical
for imaging, only the ratio of counts in tumor to
those in adjacent tissues. Methods are available to
increase this ratio, since this governs the method’s
resolution, such as the use of a form of the antibody
that targets to tumor and clears from background,
nontarget tissues rapidly: antibody fragments (Fig-
ure 1). The smaller the fragment, the more rapid the
targeting and clearance from background, but also
the shorter the magnitude of uptake in tumor.
Therefore, Fab’ and F(ab’)2 fragments of im-
munoglobulins are the preferred targeting agents for
RAID, and it is conceivable that recombinant gene
cloning methods will provide even smaller frag-
ments, such as single-chain antibodies (SCA) for
even more rapid tumor targeting (Figure 1). The
smaller the size of the immunoglobulin, the lower its
immunogenicity in humans. Hence, SCA and Fab’
molecules may prove to be the best for human use
in RAID because of their reduced evocation of
HAMA responses, limiting the repeated use of these
animal proteins. Of course, reengineered antibodies
that have human regions of immunoglobulin com-
bined with minimal amounts of the murine binding
portion of the antibody would similarly decrease im-
munogenicity (Figure 1). Whether fragments of
totally human monoclonal antibodies are the ul-
timately desired agents remains to be determined,
since human MAbs have been difficult to generate
and produce in large quantities.
The nature of the radionuclide used for imaging
also is very important from the aspects of image
quality, background activity, optimal imaging
times, and cost. Table 1 summarizes the attributes
VOL. 87 NUMBER 11 NOVEMBER 1990
915
of the more common radionuclides in use for RAID,
and it is apparent why technetium-99m ("mTc) is the
preferred agent in nuclear medicine. However, until
very recently it has been a major problem to achieve
a stable linkage of"mTc to antibodies and preferably
the fragments, since the short, 6-h half-life ofWmTc
mandates that rapid tumor targeting be achieved.
A number of groups recently have reported the suc-
cessful labeling of antibodies and antibody frag-
ments with "mTc, and these agents are in various
stages of clinical trials.33'35 An example of rapid "mTc-
antibody targeting and imaging is shown in Figure
2, about three hours after injection of the agent,
revealing multiple sites of cancer, some of which
were not seen on CT scans. Therefore, now that the
"mTc-labeling technology has been solved, it is a
straightforward process to select the appropriate an-
ticancer antibodies for the RAID of many different
tumor types. Obviously, pancarcinoma antibodies,
such as against carcinoembryonic antigen (CEA),
have the widest tumor application.
The potential and current indications for cancer
RAID are summarized in Table 2. The two most
well-established indications are: confirmation of a
tumor site first disclosed by another method, such
as by CT scan, whereby the RAID study provides!
additional functional information that the lesion is
truly growing and producing a cancer-associated
marker; and disclosure of recurrence by RAID in a
patient in whom this is suspected, such as when
there is a rising tumor-marker titer in the blood, e.g.
CEA, AFP, hCG, but not detectable by any other
methods.37 The roles of RAID in initial diagnosis, in
staging of cancer, in assessment of residual disease
during or following surgery, and in qualifying an
antibody for therapy, are in earlier phases of in-
vestigation, but nonetheless appear to be likely ap-
plications. To date, several thousand patients have
been studied with radiolabeled antibodies in RAID
studies, and usually between 60 and 90 percent of
known lesions have been disclosed correctly, depend-
ing on the antibody and its form, the radionuclide,
planar, and/or SPECT scanning methods. Table 3
summarizes the current status of cancer RAID, in-
dicating that very small tumors have been revealed
by this method, including occult neoplasms.313336'39
RADIOIMMUNOTHERAPY (RAIT)
One of the earliest attempts at RAIT was recorded
by Beierwaltes in 1951, when he achieved a nine-year
Table 3. Current status of antibody imaging.
Subject
Safety
Sensitivity
Small tumors
Findings
Radioactive antibodies have been found to be safe in over 7,000 patients studied worldwide.
On a tumor-site basis, results between 60 and over 90 percent sensitivity and specificity have
been reported, with the highest accuracy rates found for MAbs labeled with 131l, 123l, or99mTc.
Tumors as small as 0.4 to 0.5 cm have been disclosed with"mTc-MAbs, especially with emission
tomography, but resolution usually is in the range of 1.0 to 2.0 cm.
Occult tumors Tumors missed by other methods, including CT, have been revealed by antibody imaging.
Serum antigen Antibody imaging can be positive even before the antigen titer in the blood is elevated. Com-
plexation with circulating antigen does not compromise antibody imaging.
HAMA
Repeated injections of animal antibodies result in human antibodies against these foreign
proteins, that can compromise antibody targeting.
Table 4. Isotopes for antibody therapy.
Isotope Half-Life Decay Mode Advantages Disadvantages
131 1
8 d
P
inexpensive; images
Deiodination; thyroid uptake
90y
2.5 d
P
Indium chemistry
Leaches off chelate; bone
uptake; no images
1B6Re
3.8 d
P
Tc-chemistry; images
Availability
,88Re
17 h
P
Generator produced;
Tc-chemistry; images
67Cu
2.5 d
P
Images
Availability
ai,At
7 h
«; Electron
capture
Iodine chemistry;
short range
No images
1 25 1
60.4 d
Electron capture
(Auger)
Short-range electrons
Poor images
916
NEW JERSEY MEDICINE
ion
*y
i, ei
IAH
::
:nd
lid(
It
in
lied
] d
B
Figure 2. Following radiation to the rectum, a 56-year-old man
underwent a resection for Dukes' C2 adenocarcinoma of the
rectum in August 1988. In January 1989, he received additional
local irradiation therapy and was started on chemotherapy, that
consisted of leucovorin combined with 5-FU weekly. His
plasma CEA ranged from 19 ng/mL in January 1989 to 53
ng/mL at the time of the RAID study in March 1989. The patient
received 1 mg of lmmu-4 (NP-4) anti-CEA MoAb Fab' labeled
with 8.8 rnCi95mTc. The abdominal CT (A) taken 21 days before
the RAID study shows multiple liver lesions (arrows). RAID in
the three-hour transverse SPECT views of the abdomen (B)
confirmed the lesions (arrows). The RAID studies demonstrated
several additional lesions not seen on the CT scans (reprinted
with permission).
;q
:
Jflr
complete remission of a metastatic melanoblastoma
with a very low dose of iodine-131-conjugated (131I-
conjugated) rabbit immunoglobulin.40 Spar com-
pleted clinical trials of RAIT with 131I-labeled anti-
fibrin antibodies reporting some tumor responses.41
Clinical studies of RAIT were not pursued much
further until interest was stimulated by the first
clinical report of successful cancer detection by
CEA-RAID.25 The discovery of MAb production by
Kohler and Milstein3 then led to a flurry of activity,
since pure MAbs could be generated to almost any
tumor desired. However, progress has been slower in
RAIT than in RAID, and this probably is due to
RAID only requiring a differential ratio of counts in
tumor as compared to adjacent tissues, whereas
RAIT depends on dose and duration of radioactivity
delivered relatively selectively to the tumor. The
majority of studies have involved 131I-conjugated to
murine whole antibodies, and at present there is a
paucity of evidence that radioiodinated MAbs by
themselves have shown consistent and reproducible,
major tumor responses. Order and coworkers at the
Johns Hopkins Cancer Center have shown that when
combined with other therapies, 131I-conjugated anti-
ferritin antibodies made in different animals can
have important response rates (40 percent) in
hepatocellular cancers.42 Similar work by Lenhard in
Hodgkin’s disease,43 and by others in various
lymphomas,44 43 have indicated that the radio-
sensitive lymphatic tumors respond much better to
RAIT than the more frequent and lethal solid
tumors. These findings support the conclusion that
RAIT, if it can overcome the relatively low rad doses
delivered to tumor, could eventually play an impor-
tant role in the therapy of many cancers.49
Response rates in metastatic colorectal and other
gastrointestinal cancer patients treated by RAIT,
usually with l3,I-labeled CEA, MAbs generally are
poor. The tumor doses achieved to date usually have
been less than 2000 cGy, whereas more than 5000
cGy most probably is the minimum required for
response.4' In hepatocellular carcinoma, Order re-
ported tumor doses of 1100 to 1200 cGy on the aver-
age, resulting in therapeutic responses when com-
bined with doxorubicin and fluorouracil. The Johns
Hopkins group reported 11 patients have had con-
version of nonresectable to resectable hepatocellular
cancer by the use of radiolabeled antibodies, and
that of the 11 patients, 80 percent have shown a
survival of more than three years.42 This group also
has reported on 37 patients with nonresectable in-
trahepatic cholangiocarcinoma.50 Using radiation
and chemotherapy induction followed by cyclic ther-
apy with different 131I-CEA MAbs, there was a 33
percent remission rate with a median survival of 6.5
months, and for remitters, the median survival was
15.2 months. The longest partial remission was four
years.
Brady treated 15 patients with glioma with
iodine-125-labeled (125I-labeled) anti-epidermal
growth factor receptor (EGFR) MAb, reporting one
complete remission and two partial responses. The
internalization of the 125I radionuclide results in
Auger electron irradiation, that is particularly
cytotoxic to the cell nucleus.51 131I-labeled antibodies
to EGFR, or to placental alkaline phosphatase, were
used by Kalofonos to treat 10 patients with recurrent
grade III or IV glioma intravenously or by internal
carotid artery infusions, and 6 patients showed
clinical improvement lasting from six months to
more than three years. Other antiglioma antibodies
also have shown promising tumor targeting in pa-
tients.53 Neuroblastoma- and melanoma-targeting
antibodies have been developed and demonstrated
by Cheung54 to have antitumor effects both as naked
antibody and when conjugated with 131I.
Lymphomas and leukemias are preferred targets
for RAIT because of their radiosensitivity and good
vascularization, and patients having a poorer or in-
frequent HAMA response.44 48 Our own studies with
a new B-cell specific antibody, EPB-2 (or LL2), have
demonstrated very good targeting in non-Hodgkin’s
B-cell lymphoma, as well as responses to low doses
of 131I-labeled MAb.48,55'56 These encouraging results
with this B-cell lymphoma MAb have stimulated
our expansion of these trials to assess the effects of
higher doses of radioactivity and of antibody, as well
as the role of different dosage schedules.
It is clear that RAIT has become a field of intense
VOL. 87— NUMBER 11 NOVEMBER 1990
917
investigation at the experimental and the clinical
levels. What are the current problems and limi-
tations, and how can these be overcome? It certainly
is easier to identify the problems than the solutions,
but it is reassuring from the studies cited that con-
siderable progress has been made in RAIT, particu-
larly in the past few years.
131I is a very suitable radionuclide for therapy,
having an average beta energy of 0.183 meV and a
physical half-life of eight days for cytotoxic
purposes, and emitting gamma rays for tumor imag-
ing and quantitation. It also is very easy to label
antibodies, and the minimal toxicity to normal tis-
sues (hypothyroidism) and the extensive clinical ex-
perience with this isotope all favor its use. However,
it has shown relatively low tumor dose rates of
5 cGy/h in clinical studies.49 Other potential isotopes
for RAIT are listed in Table 4. 125I emits Auger elec-
trons, whose short-range energy can affect the nu-
cleus and, thus, destroy cells once the electrons are
internalized. This isotope is being used after con-
jugation to MAbs against EGFR.5152 Yttrium-90
("Y) is a pure beta emitter of 0.937 meV with a
physical half-life of 2.7 days, and has been used as
a colloid preparation in the treatment of arthritis.
In clinical experience, a much higher radiation dose
to tumor is achieved with “Y conjugated to MAbs
than with 131I, but at increased host toxicity. One of
the problems with this metallic radionuclide is the
difficulty of achieving a tight and stable linkage to
MAb, resulting in bone toxicity.57 However, im-
proved chelates are in development and testing
stages.58,59
Rhenium-186 (186Re) and rhenium-188 (188Re) have
gained much interest recently because of the simi-
larity in their chemical properties to"mTc. 186Re has
an average beta energy of 0.781 meV and a physical
half-life of 3.8 days, and emits a gamma energy of
137 keV for imaging and quantitation of uptake.
l88Re has a maximum beta energy of 2.116 meV and
a physical half-life of 17 h, with a gamma energy
component of 155 keV for imaging and quantitation.
In addition to beta-emitting isotopes, alpha emis-
sion from bismuth-212 and astatine-211, that ir-
radiate at very short distances, have been used in
laboratory studies, and appear to hold promise for
the therapy of circulating tumor cells or of micro-
metastases.
It is apparent from this short list that many poten-
tial therapeutic radionuclides for conjugation to
antibodies are available, but the problem has been
to achieve tight and stable linkages of these isotopes
in sufficiently high number to the antibodies
without affecting the MAb’s immunoreactivity and
targeting properties. As advances are made in
References available upon request.
bioconjugate radiochemistry, more potential radio-
nuclide candidates will enter RAIT trials. However,
this will only partly affect the current limitation of
only a small portion of the injected MAb becoming
accreted in the target site. The advantage of RAIT
is that the radiation deposited by an antibody can
destroy cells at a distance, thus, not requiring anti-
body uptake by each cell in the tumor. Depending
on the form of radiation, the distance can be large,
such as with beta emitters, or short, as in the case
of alpha energy. Thus, beta energy is more ap-
propriate for large tumors, and those isotopes emit-
ting energy traversing shorter distances are better
suited for the treatment of very small tumors or
clusters of tumor cells. Various methods to increase
the tumor accretion of MAbs are under investiga-
tion, such as affecting tumor vascularization and
vascular permeability, and increasing antigen ex-
pression.60,61 A simpler approach has been the direct
injection of the MAb into the tumor cavity, such as
intrapleural and intraperitoneal applications.62 Both
131I-labeled and^Y-labeled MAbs have been adminis-
tered intraperitoneally, and overall responses have
been limited, with less extensive disease responding
better than advanced cases.63 Intrathecal RAIT also
has been applied to neuroectodermal tumors,64 and
it seems that this does not result in any significant
toxicity, thus holding much promise for the treat-
ment of tumors in the cranium.
The administration of high and repeated doses of
radiolabeled MAbs has been limited by the HAMA
response and by myelotoxicity.49,65 The former may
be avoided by the development and use of human
or humanized MAbs, while the latter may be over-
come by autologous bone marrow transplantation
and/or the administration of marrow-stimulating
cytokines, such as interleukin-1, interleukin-3,
granulocyte colony-stimulating factor, and granu-
locyte-macrophage colony-stimulating factor.47,66
It is apparent that many problems in RAIT need
to be solved, and that, its future may lie in its ju-
dicious combination with other cancer therapeutic
modalities, such as an adjuvant with primary sur-
gery, and in combination with chemotherapy to
remit advanced malignancy. These opportunities
will need to be studied once the basic issues of the
physics, radiobiology, bioconjugate radiochemistry,
antigen site, quantity and expression, antibody
form, structure and immunogenicity, and tumor ac-
cretion are optimized. This form of systemic radi-
ation therapy, which should serve as a prelude to
chemoimmunotherapy, may provide a rational
alternative to the treatment of already disseminated
cancers, and to the reduction of dissemination in
adjuvant protocols. ■
918
NFW .IFRSFY MFIOiriNF
Nuclear Cardiology:
Perfusion, Viability, and Function
MARGARET LAMANNA, MD
Nuclear cardiology research projects fall into
two basic categories: myocardial perfusion
and cardiac function. In the area of
myocardial perfusion there has been a twelvefold
increase in positron-emission tomography (PET)
studies and a tripling in single-photon emission com-
puterized tomography (SPECT) studies in the past
five years. Cardiac SPECT research using 201
thallium as well as technetium-99m ("mTc) com-
pounds for myocardial perfusion/function is under-
way. The advantages of technetium compounds lie
in their ability to detect myocardial perfusion and
myocardial function with a single injection.
MYOCARDIAL PERFUSION IMAGING
The purpose of myocardial perfusion imaging is to
evaluate stenosis versus flow reserve of the
myocardium; to evaluate stress versus rest imaging;
to assist in the diagnosis/prognosis of coronary artery
disease; and to determine myocardial viability. The
issue of ischemia versus scar is key. The standard
isotope for myocardial perfusion is thallium, a
potassium analog (Table 1). Technetium-based
myocardial perfusion imaging protocols include the
use of cationic technetium complexes such as
Cardiolite (isonitrile, RP 30A) and Cardiotec, a neu-
tral lipophilic, highly ex-
tracted myocardial per-
fusion agent with rapid
myocardial clearance — a
Dr. LaManna is medical director,
Nuclear Imaging Systems, Inc.,
Swarthmore, PA. Requests for
reprints may be addressed to Dr.
LaManna, Nuclear Imaging Sys-
tems, Inc., 740 South Chester
Road, Suite C, Swarthmore, PA
19081.
technetium Bato compound. There are potential
clinical advantages of technetium compounds;
technetium is a superior isotope for imaging; it is
compatible with planar/SPECT instrumentation;
perfusion and function studies can be performed
simultaneously; the isotope is readily available;
there is flexible scheduling; and there is an op-
portunity to increase nuclear cardiology studies
(Table 2). The potential clinical applications of
these agents include their ability to detect both per-
fusion and function abnormalities (Table 3).
Clinical trials ofMraTc teboroxime (Cardiotec) in
patients who also received 201 thallium have been
completed. The goals were to assess the use ofWraTc
Cardiotec in patients who received a 201 thallium
stress and a redistribution examination by compar-
ing the Cardiotec imaging results with the results of
thallium scintigraphy, and to determine the time
savings associated with the use of technetium
Cardiotec compared to the time required to perform
a thallium stress and a redistribution examination.
The total study time is approximately two hours for
the technetium agents; five hours for thallium. The
"mTc isonitriles have been used in both adults and
children to assess cardiac function and myocardial
perfusion.
Also, there are several alternatives to treadmill
and upright bicycle testing including arm
ergometry, oral and intravenous dipyridamole, in-
travenous adenosine, and transesophageal atrial
pacing. We participated in a multicenter crossover
comparison of intravenous adenosine (Adenoscan®)
versus exercise in the noninvasive assessment of cor-
onary artery disease by SPECT.
Pharmacologic coronary vasodilation with
dipyridamole has its limitations (Table 4). The oral
preparation is slow in onset of action and involves
FR 1990
919
a prolonged procedure. The recommended in-
travenous dose produces widely variable and fre-
quently submaximal coronary vasodilation. Side ef-
fects such as chest discomfort, ST depression, ar-
rhythmias, headaches, flushing, dizziness, light-
headedness, and gastrointestinal complaints are
common with both preparations. Symptoms are not
managed easily by dose reduction due to the relative
long half-life of dipyridamole. Theophylline, a
direct-acting adenosine antagonist often is required.
We investigated the use of adenosine (Table 5), a
potent coronary vasodilator, with rapid onset of ac-
tion and an approximate half-life of ten seconds to
induce coronary vasodilation in association with
thallium SPECT scintigraphy. The postulated
adenosine mechanisms (Table 6) include interaction
with Al and A2 receptors and altered synthesis of
cyclic AMP; guanine nucleotide proteins are in-
volved as mediators, and calcium ion movements are
produced.
The purpose of this study was to determine the
degree of concordance between Adenoscan - and ex-
ercise thallium in patients with angiographically sig-
nificant coronary artery disease. Secondary objec-
tives included the determination of the degree of
sensitivity, specificity of Adenoscan® and exercise
thallium in detecting significant coronary artery dis-
ease as defined by cardiac catheterization, and the
determination of the reliability of Adenoscan® and
exercise thallium to predict the location and severity
of coronary artery disease (Table 7).
In addition, we investigated the effect of
dipyridamole in moderate to severe coronary
stenosis following cardiac catheterization; the
purpose of the study was to evaluate the effect of
dipyridamole on coronary blood flow in the presence
of moderate to severe coronary artery stenosis. There
were no adverse hemodynamic effects observed
while on dipyridamole. There were no changes in the
PR or QRS intervals. Nine stress EKGs were
ischemic with and without dipyridamole. Thallium
and cath scores were determined independently by
doubleblinded observers. Analyzing the thallium
bullseye polar plots display based on short-axis im-
ages, 7 regions were better on dipyridamole, 12 re-
gions were unchanged, and 9 regions were worse (3
regions significantly were worse and 6 regions were
mild). In all cases, there was greater than 75 percent
stenosis of the RCA or the LAD. We concluded that
dipyridamole in therapeutic doses causes hemo-
dynamically significant redistribution in coronary
blood flow.
TRANSESOPHAGEAL ATRIAL PACING
Transesophageal atrial pacing (TAP) is an ideal
alternative to conventional stress testing in patients
unable to exercise: patients in poor physical health,
with peripheral vascular disease, thrombophlebitis,
claudication, arthritis, paraplegia, or recent to
myocardial infarction. TAP can be utilized for burst- ; eli
pacing in the treatment of SVT arrhythmias and in el
the differential diagnosis of complex arrhythmias. t(
Our results indicate this procedure was tolerated ti
- — — It
Table 1. Thallous chloride (thallium-201).
Thallium-201 is a cyclotron produced nuclide with half-
life of approximately 73 hours.
Limitations include: photons easily attenuated by body
tissues (80 Kev Hg x-rays). Long physical and biological
half-lives increase radiation dosimetry, limiting patient
doses to 2 to 4 mCi. Imaging procedure involves a stress
examination followed by a second examination after re-
distribution that can take from 4 to 72 hours.
Table 2. RP-30.
Potential Clinical Advantages
• Superior isotope for imaging
• Compatible with planar/SPECT instrumentation
• Perfusion and function studies
• Readily available
• Flexible scheduling
• Opportunity to increase nuclear cardiology studies
Table 3. RP-30.
Potential Clinical Applications
Perfusion
• Ischemia
• Infarction
• Planar
• Gated Planar
• SPECT
Function
• Gated wall motion
• First pass ejection fraction
T able 4. Limitations of pharmacologic coronary
vasodilatation.
Dipyridamole: Limitations
Oral preparation— slow onset of action, prolonged
procedure.
Recommended intravenuous dose produces widely vari-
able and frequently submaximal coronary vasodilation.
Side effects— chest discomfort, ST depression, ar-
rhythmias, headaches, flushing, dizziness, light-
headedness, and gastrointestinal complaints.
Symptoms not easily managed by dose reduction rela-
tive long half-life.
Theophylline— a direct-acting adenosine antagonist
often is required.
920
NEW JERSEY MEDICINE
smsssim
:v»r
quite well without difficulty in patients with no his-
tory of esophageal disorders. The esophageal pacing
electrode is swallowed in capsule form until proper
electrode pacing capture can be documented by a P
to QRS ratio of at least 1:1 or greater on the elec-
trocardiogram. Once the proper position is main-
tained and documented via the ECG, pacing can be
initiated using a pulse width of 10 milliamps and
pulse width of 6 to 28 milliamps. The pacing system
is set at 20 beats/min above the patient’s baseline
heart rate and incremented sequentially. All pa-
tients are paced to 85 percent of their age-predicted
maximal heart rate, unless chest pain or ECG
changes occur before 85 percent is reached. When
the patient has reached the 85 percent age-predicted
rate, thallium is injected. The patient is paced for
an additional five minutes and imaging is per-
formed. This test is very well tolerated and com-
parable in sensitivity to treadmill thallium imaging.
POSITRON EMISSION TOMOGRAPHY
Investigators reported PET identifies transient de-
fects (ischemia) in 34 percent of myocardial seg-
ments showing a fixed defect (infarction) by
SPECT. Because PET actually is the gold standard
for assessing myocardial viability, the future of
cardiac imaging may lie in PET. Pharmacologic
stressing with dipyridamole/ruthenium-82 (R2Ru)
Table 5. Characteristics of adenosine.
• Coronary vasodilator
• Rapid onset of action
• Short half-life— 10 seconds
• Titrate to tolerance— max 140 mcg/kg/min
• Infusion— 6 min— thallium at 3 min
Table 6. Adenosine mechanisms.
• Interacts with A1 and A2 receptors
• Altered synthesis of cyclic amp
• Guanine nucleotide proteins involved as mediators
• Calcium ion movements are produced
Table 7. Purpose.
Primary Objective
Determine degree of concordance between Adenoscan®
and exercise thallium in patients with angiographically
significant CAD.
Secondary Objectives
Determine the degree of sensitivity specificity and pre-
dictive accuracy of Adenoscan® and exercise thallium in
detecting significant CAD as defined by cath.
To determine reliability of Adenoscan® and exercise
thallium to predict location and severity of CAD.
PET as well as ammonia/fluorodioxide glucose
(1HFDG), PET imaging may help to distinguish in-
farction from acutely “stunned” or chronically
ischemic “hibernating” myocardium. However, this
is an expensive technology. PET scanners range
from $950,000 to $2.5 million. For rubidium
dipyridamole stressing, a $20,000 generator is re-
quired every 25 days for rubidium production: for
ammonia/18FDG studies, a $2 million cyclotron is
required. Myocardial metabolism also may be
assessed with carbon-11 ("C) acetate, UC palmitate,
or fatty acid analogs such as IPPA that may provide
an index of fatty acid metabolism (IPPA can be
utilized with SPECT imaging). A new and exciting
area of neurocardiology involves isotopes such as
MIBG and “C hydroxyephedrine.
CARDIAC FUNCTION
In the area of cardiac function, left-sided regurgi-
tation was evaluated on first pass exercise angiog-
raphy, and abnormal left and right ventricular func-
tion with exercise in symptomatic mitral valve
prolapse. A followup of patients with chronic aortic
regurgitation before and after valve replacement is
in progress and we are testing cardiac function with
radionuclide ventriculography after percutaneous
aortic balloon valvuloplasty. We also are assessing
the long-term effects of valve repair and replacement
using radionuclide ventriculography.
Radionuclide ventriculography was performed
pre- and postpercutaneous aortic balloon
valvuloplasty (ABV) in 50 consecutive patients, with
long-term followup to 18 months postvalvuloplasty.
We determined that successful ABV is associated
with significant reduction in the AV gradient.; there
was significant increase in the LVEF between the
one and six-months’ followup and a significant de-
crease in LVEDV and LVEDVI between the one and
three-months followup demonstrated by radio-
nuclide ventriculography. It was determined that
aortic balloon valvuloplasty is associated with over-
all improvement in left ventricular function pa-
rameters at three and six months that were not ap-
parent at the initial postvalvuloplasty study. Radio-
nuclide ventriculography was found to be a useful
tool in the followup of ABV patients.
The management of patients with chronic aortic
regurgitation is best performed utilizing serial radio-
nuclide ventriculograms. Patients with normal rest-
ing, left ventricular ejection fraction, normal ex-
ercise tolerance, and normal ejection fractions with
exercise could be followed annually. However, pa-
tients with an abnormal ejection fraction response
to exercise, should be followed at three- to six-month
intervals. Patients with abnormal resting LVEFs
and exercise intolerance or symptoms should under-
go cardiac catheterization/valve replacement.
VOL. 87— NUMBER 11 NOVEMBER 1990
921
CONCLUSION
Future adoption of PET imaging as a clinical
rather than a research tool probably will depend
upon the development of small, relatively inexpen-
sive cyclotrons, better annihilation photon detec-
tors, more efficient automated systems for radio-
pharmaceutical incorporation of short-lived positron
emitters, and regional PET centers. HCFA presently
is considering the reimbursement issues that impact
on myocardial viability studies with PET. In spite
of these issues, nuclear medicine research continues
to blossom. The National Institutes of Health
budget for diagnostic imaging research in fiscal year
1988 totaled $866.6 million; nuclear medicine proj-
ects represented 43 percent of this total. Research
with positron emitters and PET totaled $20.5
million, and research with radiolabeled monoclonal
antibodies totalled $6.2 million.
Nuclear medicine plays a vital role in patient
management. Diagnostic screening procedures in
nuclear medicine influenced patient management in
63 percent of hospital inpatients, and in quan-
titative/monitoring studies, we influenced manage-
ment in 56 percent of cases. The future of PET,
radiopharmaceuticals, monoclonal antibody imag-
ing, and mobile nuclear cardiology are promising. ■
REFERENCES
1. Wilson RF, Christensen B, Zimmer S, et al.: Effects
of adenosine on the coronary circulation in humans. J Am
Coll Cardiol 13:132, 1989.
2. Mahmarian JJ, Staudacher RS, Hixson JB, et al.:
Thallium-201 scintigraphy after maximal pharma-
cological coronary vasodilation with adenosine. J Nucl
Med 30:760, 1989.
3. Trakhtenbroit AD, Cheirif J, Kleiman NS, et al.:
Intravenous adenosine echocardiography, a new pharma-
cologic stress test; preliminary results and comparison
with simultaneous thallium scintigraphy. J Am Coll
Cardiol 15:234A, 1990.
4. Cheirif J, Kleiman S, Verani MS, et al.: Intravenous
adenosine echocardiography, a new pharmacologic stress
test: Preliminary results and comparison with simul-
taneous thallium scintigraphy. J Am Coll Cardiol 234:15,
1990.
5. Siffring PA, Gupta NC, Mohiuddin SM, et al.:
Myocardial uptake and clearance of Tl-201 in healthy
subjects: Comparison of adenosine-induced hyperemia
and exercise stress. Radiology 173:769-774, 1989.
6. Staudacher RA, Mahmarian JJ, Hixson JB, et al.:
Adenosine thallium-201 scintigraphy: Feasibility, safety,
and initial results in man. J Am Coll Cardiol 13:161A,
1989.
7. Mahmarian JJ, Johnston DL, Verani MS:
Assessment of coronary artery anatomy early after acute
myocardial infarction with adenosine thallium-201 tomog-
raphy. Circulation 80:11-308, 1989.
8. Mahmarian JJ, Johnston DL, Boyce TM, et al.: De-
tection of residual ischemia early after acute myocardial
infarction using adenosine/thallium-201 single-photon
emission computed tomography. Circulation 80:11-521,
1989.
9. Nguyen T, Heo J, Ogilby D, et al.: Adenosine-
SPECT thallium-201 myocardial imaging. J Am Coll
Cardiol 15:229A, 1990.
10. Mahmarian JJ, Johnston DL, Verani MS:
Assessment of coronary artery anatomy early acute
myocardial with adenosine thallium-201 tomography.
Circulation 80:4, 1989.
11. Belvedere D, Goyna E, VandeScreek P, et al.: In-
ability of elect rocardiographic changes and chest pain dur-
ing infusion of adenosine to predict the presence of cor-
onary disease. J Am Coll Cardiol 44A:15, 1990.
12. Panidis IP, McAllister M, Ross J, Mintz GS: Preva-
lence and severity of mitral regurgitation in the mitral
valve prolapse syndrome: A doppler echocardiographic
study of 80 patients. J Am Coll Cardiol 7:975-981, 1986.
13. Abdulmassih S, Iskandrian A, et al.: Principles and
applications. Nucl Cardiac Imaging 6:425-466, 1989.
14. Johnson LL, Powers EF, Tzau WR, et al.: Left ven-
tricular volume and ejection fraction responses to exercise
in aortic regurgitation. J Am Coll Cardiol 51:1542, 1983.
15. Huxley RL, Gaffney FA, Corbett X Jr, et al.: Early
detection of left ventricular dysfunction in chronic aortic
regurgitation as assessed by contrast angiography,
echocardiography, and rest and exercise scintigraphy. J
Am Coll Cardiol 51:1542, 1983.
16. Lewis SM, Riba AL, Berger HJ, et al.: Radionuclide
angiographic exercise left ventricular performance in
chronic aortic regurgitation: Relationship to resting
echocardiographic ventricular dimensions and systolic
wall stress. J Am Heart 2:103-498, 1982.
17. Dehmer GJ, Firth BG, Hillis LD, et al.: Alterations
in left ventricular volumes and ejection fraction at rest and
during exercise in patients with aortic regurgitation. J Am
Coll Cardiol 48:17, 1981.
18. Goldman ME, Packer M, Horowitz SF, et al.: Rela-
tion between exercise-induced changes in ejection fraction
and systolic loading conditions at rest in aortic regurgi-
tation. J Am Coll Cardiol 3:924, 1984.
19. Branzi A, Loli C, Piovaccari G, et al.: Echocardio-
graphic evaluation of the response to after load stress test
in young asymptomatic patients with chronic severe aortic
regurgitation; sensitivity of the left ventricular end-
systolic pressure-volume relationship. Circulation 70:561,
1984.
20. Borer JS, Rosing DR, Kent KM, et al.: Left ven-
tricular function at rest and during exercise after aortic
valve replacement in patients with aortic regurgitation. J
Am Coll Cardiol 44-1297, 1979.
21. Safian RD, Berman AD, Diver DJ, et al.: Balloon
aortic valvuloplasty in 170 consecutive patients. J Med
319:125-130, 1988/
22. Allen ML, Vacek JL, Preston DF, et al.: Thallium
cardiac stressing by esophageal pacing. J Nucl Med
3:135-138, 1989.
23. McAfee JG, Kopecky RT, Frymoyer PA: Nuclear
medicine comes of age: Its present and future roles in
diagnosis. Radiology 174:609-620, 1990.
24. Tamaki N, Yonekura Y, Senda M, et al.: Value and
limitation of stress thallium-201 single photon emission
computed tomography: Comparison with nitrogen- 13 am-
monia positron tomography. J Nucl Med 29:1181-1188,
1988.
922
NEW JERSEY MEDICINE _
Vascular Surgery and
Cardiac Pacing
DAVID E. EISENBUD, MD
Advances in vascular surgery and in the management of cardiac arrhythmias
have benefited thousands of patients in recent years. In New Jersey, one
of several groups provides outstanding leadership in these important areas.
The vascular surgical group at Newark Beth
Israel Medical Center (NBIMC) has had a
longstanding commitment to the laboratory
and clinical investigation of cardiac and peripheral
vascular problems. The experimental laboratory, es-
tablished by Dr. Victor Parsonnet in 1958, pursues
various interests, including: cardiovascular devices
(pacemakers, vascular
grafts, and stents); cellular
biology of vascular disease;
noninvasive methods for
Dr. Eisenbud is affiliated with the
Department of Surgery, Newark
Beth Israel Medical Center. Re-
quests for reprints may be ad-
dressed to Dr. Eisenbud, Newark
Beth Israel Medical Center, 201
Lyons Avenue, Newark, NJ
07112.
detection and monitoring of vascular problems; and
clinical reviews of relevant topics.
INTRAVASCULAR STENTS
The growing worldwide interest in the field of in-
travascular stents stems from the emergence of en-
dovascular interventions — percutaneous trans-
luminal coronary angioplasty (PTCA) and periph-
eral angioplasty (PTA), laser angioplasty, and
atherectomy. It is estimated that over 200,000 PTA
and PTCA procedures will be performed in the Unit-
ed States this year. Though these procedures are
appealing because they are minimally invasive, the
failure rate within the first six months may be as
high as 30 percent.
There are several mechanisms of early failure.
Elastic recoil of the blood vessel wall can cause re-
current stenosis after the balloon is removed.
VOL. 87— NUMBER 11 NOVEMBER 1990
923
Alternatively, damage done to the arterial wall dur-
ing dilatation may lead to dissection of the wall,
with ultimate stenosis or closure of the vessel. Suc-
cessful dilatation of atherosclerotic lesions requires
rupturing the intima and at least part of the media;
it is said that every successful dilatation necessarily
involves sufficient local trauma to lead to arterial
dissection. In fact, angiograms taken immediately
after successful PTA or PTCA often demonstrate a
definite local dissection.
To combat both elastic recoil and to secure pos-
sible intimal flaps against the media, several groups
have investigated intravascular stents. The purpose
of such devices would be to push the flap back in
place and allow for proper healing, while preventing
intramural dissection and restenosis from contrac-
tion of the smooth muscle in the vessel wall.
Our involvement in this area originated from an
interest in dissection of a larger vessel, the aorta.
Acute aortic dissection is an extremely lethal con-
dition requiring major emergency surgery for
survival. Untreated patients with aortic dissections
have a 28 percent one-day mortality, and only 10
percent survive three months. In fact, many of these
patients who present for emergenc}' evaluation die
in the emergency ward or angiography suite before
surgery can be done. In 1985, a patient recovering
from surgical repair of an acute aortic dissection
designed a self-expanding polyester stent that could
be introduced into the aorta from the femoral artery
to expand and obliterate a dissection.
We also investigated other stent materials, as it
was felt the strength of the polyester mesh might not
be sufficient to prevent recoil of a strong arterial
wall; and it would be more convenient to dilate the
arterial lesion and insert the stent simultaneously.
Fluoroscopic visualization also was difficult with the
polyester stent; the mesh needed to have metal in-
tertwined with it. Thus, we turned to stainless steel2
and tantalum stents.
The current stent, made of tantalum,3 4 is crimped
onto a balloon angioplasty catheter, and is expanded
by the balloon during dilatation. It is visualized eas-
ily using fluoroscopy, can be cut to any length to
accommodate any lesion, and will acccommodate
curves. A model of arterial disease was sought to test
its usefulness after initial studies of biocompatibility
and ease of insertion (similar to those done with the
polyester stent) showed no problems with the metal
stents (Figure 1).
At present, an application is pending with the
Food and Drug Administration (FDA) for phase I
clinical trials of the tantalum Medtronic-Wiktor
stent for iliac arterial stenoses. Twenty patients ap-
propriate for iliac dilatation will receive stents and
then be re-evaluated at six months with clinical
examination and angiography. Meanwhile, design
I m
; ter
J)'
if
it
ill
Is
It
Figure 1. Technique for obliteration of aortic dissection by stent
placement. A. Stent on balloon catheter inserted retrograde
along guidewire in true lumen. B. Proximal portion of stent on
balloon catheter inserted just proximal to point of entry of false
lumen as determined by angiogram. C. Point of entry closed
and that portion of dissection obliterated by expansion of
balloon and stent. D. Deflated balloon withdrawn into the next
portion of nonexpanded stent. E. Next portion of stent ex-
panded. F. Process is repeated until length of stent is complete-
ly expanded, thereby obliterating the dissection along its entire
length.
modifications are in progress to create an introduc-
tion system that is small enough to fit into the
femoral artery, yet will expand to the 3 to 5 cm size
necessary to stent the thoracic aorta. Our hope is
that such aortic stents will be available in emer-
gency departments and angiography suites for the
emergency nonsurgical treatment of acute aortic dis-
sections within a few years.
Stents are of potential value in situations outside
the arterial circulation. For example, venous
stenoses at the distal anastomosis of arteriovenous
dialysis grafts, are amenable to percutaneous dilata-
tion, but often are prone to rapid restenosis. Stent-
ing the venous opening may be a solution to this
problem. We are working on a modification of our
stent that will hold the urethra open but not cause
stone formation. Other potential uses for stents in-
clude tracheal stenoses, bronchial anastomoses, and
the nonsurgical creation of intrahepatic portacaval
shunts to cure portal hypertension.
NEOINTIMAL HYPERPLASIA
Neointimal hyperplasia (NIH) is one of the most
924
NFW . IFRSFY MEDICINE
vexing problems in cardiovascular surgery and inter-
ventional radiology. The disease consists of an ex-
uberant growth of smooth muscle cells and the depo-
sition of interstitial substances. It first was noted to
occur at the distal anastomosis of bypass grafts in
coronary and peripheral circulation. More recently,
it has been recognized as a universal phenomenon
that occurs at varying times after arterial injury,
laser treatment, balloon dilatation, and atherec-
tomy. As such, it represents the leading cause of
failure of properly performed surgical bypass or in-
terventional techniques.
As the functions of the endothelial cell become
elucidated, its importance in dynamically regulating
the microenvironment becomes clear. We have been
interested in the role of endothelial damage or
absence in the creation of NIH, and the possible
ability of functioning endothelium to prevent or
lessen this disease.
We have been conducting experiments with “en-
dothelial seeding” for several years. This process
involves obtaining endothelial cells (from the canine
external jugular vein) and applying them to a
prosthetic surface. We culture the cells in order to
increase their number and, thus, get better coverage
of the prosthetic surface; this procedure takes weeks.
In the most recent investigation, arteriovenous
loop grafts from the femoral artery to femoral vein
were constructed using polytetrafluoroethylene
(PTFE) grafts. Two grafts were inserted in each dog,
one seeded with endothelial cells and the other bare.
Grafts were followed with clinical examination and
duplex scans until one side developed a venous
anastomotic stenosis. This generally occurred at six
to ten weeks. Grafts then were explanted, stenoses
were measured, and graft surfaces studied for throm-
bus-free surface area, endothelial coverage, and
ability to generate prostacycline (PGI-2). It should
be emphasized that both the implanting surgeon
and the technicians analyzing the explanted grafts
were blinded to the allocation of grafts to receive
seeding or nonseeding.
The results have proved quite exciting (Figure 2).
Endothelial cell harvests were good (mean 3 x 10E5
cells) with excellent purity. Seeded grafts demon-
strated 10 to 60 percent coverage with cells in con-
trast to unseeded grafts, which had no endothelial
cells seen using scanning electron microscopy. The
seeded grafts tended to have more thrombus-free
surface area (76 percent seeded versus 63 percent
unseeded; P = 0.12). Venous anastomotic stenoses
were significantly greater in unseeded grafts (23 per-
cent versus 58 percent stenosis, seeded versus un-
seeded; P <0.04). Finally, only one unseeded graft
had any surface production of prostacycline, while
six of seven seeded grafts had appreciable PGI-2
production (6.76 ng/50 cc at 30 minutes seeded ver-
sus 2.92 unseeded; P = 0.024).
These promising results are the first indication
that NIH may be inhibited by the application of
endothelial cells to the surface of the implanted
prosthesis at the time of surgery. Further studies will
100
50
120
p = 0.04
I
p = 0.12
1
p = 0.006
IH Seeded
ITTTTO Unseeded
p = 0.027
p = 0.02
T
0.4
0.2
0.0
%
Stenosis
%
TSFA
% EC
Coverage
Thromboxane
(ng/50ml)
Prostacyclin
(ng/50ml)
Figure 2.
thrombus
on the m
Ratio
Prostacyclin/
Thromboxane
Effects of endothelial cell seeding on polytetrafluoroethylene arteriovenous grafts: percent stenosis at the distal
-free surface area (TFSA), percent endothelial coverage, thromboxane production on the midgraft, prostacycl
idgraft, and the ratio of prostacyclin to thromboxane production on the midgraft.
anastomosis,
in production
MBER 11 NOVEMBER 1990
925
be required to elucidate the mechanisms that
mediate this effect, though the increased
prostacycline on the surface of seeded grafts suggests
that the antiaggregatory effect of PGI-2 on platelets
is at work. Endothelial seeding as conducted in our
laboratory is logistically possible for human use;
after a vein is removed, endothelial cells can be
harvested and applied to a graft surface in the 30
to 60 minutes it takes to dissect the proximal and
distal vessels for the bypass.
CARDIAC PACING
Physicians from Newark Beth Israel Medical
Center have been active in developing and refining
pacemaker technology for the past 30 years. Though
many of the scientific and technical aspects of this
mature field have been settled, certain issues re-
main.1 2 3 4 5 6 The proliferation of increasingly more com-
plex pacemakers with multiple programming modes,
both atrial and ventricular leads, and the ability to
sense and provide for periods of increased require-
ment for cardiac output have created controversy
regarding indications for pacing and selection of the
appropriate device in each circumstance.7 We cur-
rently are evaluating a computer program that
weighs 24 items of demographic and physiologic data
for each patient and then recommends the most
appropriate pacer mode for that person. In addition,
it lists the most cost-effective devices available for
implantation in that mode. Another problem with
the more complex pacemakers is increased energy
utilization, requiring larger power sources and re-
sulting in lower pacer lifetime. This effect is more
significant given the longer life expectancy for pa-
tients who require pacemakers compared to 20 years
1. Eisenbud D, Parsonnet V, Wiktor D, et al. : A poly-
ester intravascular stent for maintaining luminal patency.
Texas Heart Inst J 15:12-16, 1988.
2. Trent MS, Parsonnet V, Shoenfeld R, et al: A
balloon-expandable intravascular stent for obliterating ex-
perimental aortic dissection. J Vase Surg 11:707-717, 1990.
3. Cross FL, Parsonnet V, Chokshi S, et al.: In vivo
evaluation of a new, flexible, balloon-expandable tan-
talum stent in canines. Presented at the International
Congress III, Lasers, Stents and Interventions in Vascular
Disease, Scottsdale, Arizona, November 1989.
4. Chokshi S, Hogan J, Desai V, et al.: Intravascular
ultrasound assessment of implanted endovascular stents.
Presented at the International Congress III, Lasers, Stents
and Interventions in Vascular Disease, Scottsdale, Ari-
zona, November 1989.
5. Lopyan KS, Eisenbud DE, Brener BJ: Does en-
dothelial seeding inhibit neointimal hyperplasia in arterio-
venous grafts? Presented at the 6th Annual Vascular Fel-
lows Abstract Presentation, New York, New York, April
1990.
6. Parsonnet V, Bernstein AD: Transvenous pacing: A
seminal transition from the research laboratory. Ann
Thorac Surg 48:738-740, 1989.
ago. Thus, many patients live long enough to require
reoperation for pacemaker battery change. A major
thrust of our pacer research at Newark Beth Israel
Medical Center continues to focus on developing
smaller electrodes with lower stimulation thresholds
to conserve battery capacity.
In addition, we have developed a transesophageal
left atrial pacemaker that functions through a
nasogastric tube and, thus, can be inserted rapidly
and safely for the control of sinus bradycardia and
atrial flutter.8 This may be appropriate in patients
after open heart surgery and for patients in the
emergency ward.
CLINICAL REVIEWS
With the development of a vascular registry, we
have analyzed our clinical experience. Data regard-
ing history, physical examination, angiogram,
noninvasive testing, and surgery are entered into the
computer; followup data records are completed in
the physicians’ offices. A full-time statistician enters
and analyzes the data. These clinical investigations
include use of the femoral-femoral crossover graft;
use of thrombolytic therapy for arterial and graft
occlusions;" and how to deal with significant carotid
disease in patients requiring coronary bypass.
CONCLUSION
The Newark Beth Israel Medical Center vascular
and cardiac surgical group considers basic research
and the thoughtful analysis of clinical experience to
go hand-in-hand with everyday patient care.
Through such an integrated approach to the science
of medicine many important advances have been
made that impact on patient care. ■
7. Parsonnet V, Bernstein AD: Pacing in perspective:
Concepts and controversies. Circulation 73:1087-1093,
1986.
8. Parsonnet V, Harari D, Gallagher R, et al.: Trans-
esophageal left atrial pacing and sensing using a combina-
tion bipolar electrode/nasogastric tube in post open heart
patients. Pace 12:668, 1989.
9. Brener BJ, Eisenbud DE, Brief DK, et al.: Utility of
femorofemoral crossover grafts, in Bergan JJ, Yao JST
(eds), Aortic Surgery. Philadelphia, PA, W.B. Saunders
Company, 1989, 423-438.
10. Brener BJ, Cross F, Brief DK, et al.: Comparison
of aortofemoral and femorofemoral bypass for iliac artery
occlusive disease, in Veith FJ (ed), Current Critical Prob-
lems in Vascular Surgery. St Louis, MO, Quality Medical
Publishing, Inc., 1990.
11. Eisenbud DE, Brener BJ, Shoenfeld R, et al.: Treat-
ment of acute vascular occlusions with intra-arterial
urokinase. Presented at the Society for Clinical Vascular
Surgery, Palm Springs, CA, March 1990.
12. Brener BJ, Brief DK, Alpert J, et al.: The risk of
stroke in patients with asymptomatic carotid stenosis
undergoing cardiac surgery: A followup study. J Vase Surg
5:269-279, 1987.
New Jersey Pediatric
Hematology Oncology
MILTON H. DONALDSON, MD
Less than three decades ago, adequate facilities and trained medical and
support personnel to treat pediatric cancer were not available in New Jersey.
Seven hospitals have the expertise and multidisciplinary teams that col-
laborate through the New Jersey Pediatric Hematology Oncology Network.
The first cooperative cancer study groups were
established in the early 1950s. Initially, most
of these groups consisted of institutions from
relatively restricted geographic distributions, but
soon the groups evolved with national and even in-
ternational activities.
The Pediatric Oncology Group (POG) and the
Childrens Cancer Study Group (CCSG) are the only
national study groups that conduct research in treat-
ment and biology of childhood cancer. Each group
develops study protocols to investigate various
aspects of childhood cancer, e.g. epidemiology,
etiology, pathology, surgery, radiation therapy,
chemotherapy, and supportive care. This enables
investigators in member institutions to treat the
children in a uniform manner, providing strictly
comparable data. Large volumes of data can be col-
lected and analyzed in a
Dr. Donaldson is head, Division
of Pediatric Hematology/On-
cology, Cooper Hospital/Univer-
sity Medical Center and
professor of pediatrics, UMDNJ-
Robert Wood Johnson Medical
School, Camden. Requests for
reprints may be addressed to Dr.
Donaldson, Cooper Hospital/
University Medical Center, One
Cooper Plaza, Camden, NJ
08103.
much shorter time than would be possible by any
other mechanism. This method of generating, com-
bining, and analyzing comparable data from numer-
ous institutions simultaneously expands the knowl-
edge of cancer and improves treatment more rapidly
than ever would have been possible otherwise. When
the incidence of a tumor is too low for a single group
study, efforts and resources are combined into an
intergroup study to obtain statistically significant
data.
Subsequently, a philosophy evolved to develop
geographically distributed centers to which cancer
patients would be referred for virtually all treat-
ment. There seemed to be a tacit implication that
competent and effective treatment of such diseases
was not possible by the patient’s community medi-
cal personnel and facilities. And, in many locales,
such was the case because of too few physicians and
nurses adequately trained in chemotherapy and the
lack of modern radiation facilities. However, during
the 1960s and 1970s, National Cancer Institute fund-
ing enhanced training programs that generated a
rapid increase in oncologic specialists in virtually
every discipline. As a result, there is a cadre of phy-
sicians, nurses, oncologic specialists, and technical
facilities capable of providing high-quality, coordi-
nated cancer care in many communities. In some
such programs, affiliation with a cooperative cancer
VOL. 87— NUMBER 11 NOVEMBER 1990
927
Table. New Jersey Pediatric Hematology Oncology Network
Institution/Location
Director/Phone
Group Affiliation
Valerie Fund Children’s Center
Children's Hospital of New Jersey
United Hospitals, Newark
Richard Sills, MD
201/268-8686
CCSG
Valerie Fund Children’s Center
Cooper Hospital/University Medical Center
Camden
Milton Donaldson, MD
609/342-2264
CCSG
Tomorrows Children’s Institute
Hackensack Medical Center
Hackensack
Michael Harris, MD
201/441-3231
POG
Valerie Fund Children’s Center
Monmouth Medical Center
Long Branch
Carol Lehan, MD
201/870-5106
POG
Valerie Fund Children’s Center
Newark Beth Israel Medical Center
Newark
Peri Kamalakar, MD
201/926-7161
CCSG
Valerie Fund Children’s Center
Overlook Hospital
Summit
Steven Halpern, MD
201/522-2353
CCSG
Valerie Fund Children's Center
Robert Wood Johnson University Hospital
New Brunswick
Lawrence Ettinger, MD
201/937-7898
CCSG
*CCSG = Childrens Cancer Study Group; POG =
Pediatric Oncology Group
study group has provided ready access to current
comparative treatment (phase III) trials. Some com-
munity institutions also are approved to conduct
(phase II) studies of drugs in early human appli-
cation. (Generally, trials of drugs in earliest human
usage, [i.e., phase I studies to determine mechanism
of actions, toxicities, and tolerable dosage levels],
are carried out in designated comprehensive and
medical school cancer centers rather than in com-
munity-based programs.) Participation in the coop-
erative group studies not only allows the oncology
professionals to contribute to critical and essential
research, but it also provides state-of-the-art ther-
apy to these patients.
PEDIATRIC CANCER CENTERS
This year, in the United States, there are approx-
imately 1,040,000 new cases of cancer.1 Of these,
approximately 8,000 cases occur in the first two
decades of life, the majority of which will come into
a pediatric oncology program for treatment. Since so
few pediatric cancers occur, it is understandable
that to economically maintain appropriate facilities
and professionals with competence and experience
in the treatment of these diseases, the patients need
to be concentrated in the relatively few cancer
centers with the expertise and commitment to treat
children. These cancer centers should be directed by
physicians board certified in pediatric hematology
oncology and working with a coordinated, multi-
disciplinary treatment team that must include nurs-
es and social workers trained and dedicated to on-
cology. The center should be affiliated with one of
the two national pediatric cooperative cancer study
groups.
Also vital to the child’s treatment are the dis-
ciplines of diagnostic imaging, pathology, and radi-
ation oncology. Depending on the type and location
of the malignant disease affecting the patient, the
team may expand to include general surgery, neu-
rosurgery, orthopedics, urology, ophthalmology, re-
habilitation medicine, and critical care. Each of the
physicians in these fields should have special train-
ing and competence in management of the pediatric
patient.
Specially trained educators should establish the
patient’s baseline levels as soon as possible after the
cancer diagnosis is established.- Periodically there-
after— perhaps annually for children who start treat-
ment under ten years of age — retesting should be
performed. Continuing surveillance in cooperation
with school systems detects learning disabilities
928
NEW JERSEY MEDICINE
early in their development. Retesting and subse-
quent establishment of tutoring, or whatever special
educational aid is necessary, will help the child to
best overcome the adverse impact of cancer treat-
ment on the child’s ability to gain the most from the
education system. The increasing number of chil-
dren who are cured of cancer, thus, will be enabled
to be fully educated, economically productive
adults. Current therapy is curing approximately 60
to 65 percent of children under 15 years of age.3 In
1990, it has been estimated that 1 of every 1,000
persons who have attained the age of 20 years will
be a survivor of cancer.4 If one assumes that the
median age at the time of diagnosis is ten years, that
should result in a very conservative estimate of over
200,000, and possibly over 300,000, person-years of
contributions to society by each patient cured. The
justification for having an educator as part of the
treatment team becomes clear.
A relatively new profession that should be inte-
grally involved with overall management of the child
with cancer is that of the child life specialist (CLS),
formerly known as “the play therapist.” The CLS
often is able to ferret out inaccurate thoughts and
perceptions leading to fears and anxieties in the pa-
tient, creating a lack of cooperation or overt re-
sistance to diagnostic and/or treatment procedures.
This usually enables the child to tolerate the treat-
ment experience much better and, in turn, will allow
the patient’s family to experience less anxiety and
grief.
The nurse(s) in a pediatric hematology oncology
program should be specially trained. Knowledge of
the diseases is strongly supplemented by supervised
experience and training in administration of blood
products as well as the pharmacology and adminis-
tration of cancer chemotherapeutic agents. Under-
standing of clinical research study protocols is essen-
tial for production of useful data to be provided to
the cooperative groups and local research projects.
In some institutions, data management is one of the
nurse’s responsibilities, but others maintain a sepa-
rate data manager to avoid disruption of the nurse’s
role in patient care activities.
Parents usually are profoundly distressed by the
development of cancer in their child. It is essential
that the treatment team include an experienced
pediatric psychosocial support person knowledge-
able about these diseases. More often than not, this
individual is a professional social worker but may be
a clinical psychologist. In addition to emotional and
psychological support, the family often requires aid
in managing insurance and other financial impacts
of this totally unfamiliar medical condition, trans-
portation to the treatment center, coping with sib-
ling reactions to the patient’s illness, assistance with
responding to informed consent requirements of re-
search protocols, marital or single parent stress, and
bereavement if the child dies.
The commitment and contribution of each dis-
cipline is essential. At the very least, the nursing and
social work members of the team must be full-time
with the program, though the CLS and educator
colleagues may be assigned part-time by other
divisions or departments of the institution.
THE EFFECT OF CANCER ON FAMILIES
The impact on a family is profound regardless of
the member afflicted by cancer.5 However, when the
patient is a child, the family is even more disrupted.
An adult must bring the child to the center for treat-
ment. If the child is hospitalized, usually one parent
stays with the youngster. This places virtually all
the homemaker tasks and responsibilities on the
other parent. If there are other children, it is com-
mon that relatives, neighbors, or community agen-
cies are recruited to help manage the household op-
erations in order for one parent to continue to be
employed to pay the expenses. In today’s society, it
is common that both parents are employed outside
the home in order to meet family financial commit-
ments. The child’s illness may make it necessary for
one parent to give up that job to fulfill the treatment
program schedule. This is particularly true if com-
plications develop, as commonly occur early in ther-
apy. The social worker is essential to help the family
to identify and utilize community resources, as well
as provide counseling expertise to help relieve the
emotional stress for all members of the family.
THE NEW JERSEY PEDIATRIC HEMATOLOGY
ONCOLOGY NETWORK
It is common that the family must travel long
distances to obtain expert, multidisciplinary care for
their child with cancer. The cancer center often is
in a large city with all attendant inconveniences,
resulting in even greater stress, expense, and other
problems being added to the situation.
Until only a few years ago, such was always the
case for New Jersey families. However, since the
early 1970s seven pediatric hematology oncology pro-
grams have developed throughout the state (Table).
Although programmatically organized in various
ways, each possesses multidisciplinary capability to
treat childhood cancer comprehensively. Each in-
stitution is affiliated with one of the two pediatric
cooperative cancer groups that study and treat all
types and aspects of childhood cancer. Institutional
membership in either of these two organizations
provides the most up-to-date treatment and re-
search programs available. This precludes the pa-
tient and family having to travel out of New Jersey
to avail themselves of state-of-the-art therapy.
Although the large national groups have the ad-
VOL. 87— NUMBER 11 NOVEMBER 1990
929
vantage of being able to accomplish relatively short-
term studies with statistically significant outcomes,
there are disadvantages. A smaller organization with
fewer institutions and investigators, located in a
smaller geographic area, expedites therapy and fa-
cilitates easier quality control of data through sim-
pler communications and more frequent meetings
with greater ease at a lower expense. Therefore, such
a group can perform “pilot” clinical studies that
may provide data to base definitive national group
studies. Furthermore, meetings provide a forum for
didactic presentations from which continuing educa-
tion credits can be derived. Such has been the direc-
tion of the development of the New Jersey Pediatric
Hematology Oncology Network (Table), composed
of the physicians and nurses of the seven programs
throughout the state; the Network was formally or-
ganized in 1987.
It is noteworthy that the Network was the recipi-
ent of the first grant for support of a clinical study
from the New Jersey Commission on Cancer Re-
search. The study was to evaluate the inter-
relationships of immunophenotyping, gene rear-
rangement, and cytogenetics with clinical outcome
of children who were newly diagnosed with acute
lymphoblastic leukemia and currently is in followup.
More recently, another grant has been obtained this
year by Michael Greenberg, PhD, of Rutgers Univer-
sity, with the author, to review pediatric cancer
diagnosis in the state for the period 1979 to 1988.
This effort is expected to develop an accurate set of
incidence data from which it will be possible to
promulgate prospective and retrospective epide-
miological studies.
One of the purposes of the Network is to serve as
a source of support and expert knowledge to aid the
New Jersey State Department of Health (NJDOH),
the New Jersey Chapter of the American Academy
of Pediatrics, the Medical Society of New Jersey, the
American Cancer Society, the Leukemia Society of
America, and other organizations in matters related
to hematologic and oncologic diseases in children.
For example, the Network provided a pool of experts
to guide and aid NJDOH in the development of the
recently initiated statewide neonatal hemoglobino-
pathy screening program. Subsequently, five of the
institutions have been designated as regional treat-
ment centers for confirmation of the initial screening
diagnosis, education of parents about the diseases,
and to provide comprehensive treatment, especially
of sickle cell disease.
Obviously, such a multidisciplinary group is ex-
pensive. It is not possible to underwrite the costs of
such an operation from patient fees income alone.
Therefore, each of the seven programs is dependent
on charitable fundraising to supplement the base of
funding received from the parent institution and
patient revenues. The three programs that con-
stitute the CCSG-University of Medicine and Den-
tistry program (Children’s Hospital of New Jersey,
Robert Wood Johnson University Hospital, and
Cooper Hospital/University Medical Center) receive
a modest grant from the National Cancer Institute
for protocol data management.
Hackensack Medical Center functions as part of
the Cancer Control Oncology Program, that provides
some financial support. The Hackensack program,
Tomorrows Children’s Institute, primarily is sup-
ported by the fundraising of a nonprofit organiza-
tion, Tomorrows Children’s Fund.
Clinical aspects of the other six programs are re-
ferred to as the Valerie Fund Children’s Centers for
Cancer and Blood Disorders. They are partially sup-
ported by the Valerie Fund, the oldest philan-
thropic organization in New Jersey dedicated to the
financial support of treatment programs for children
with cancer close to their home environments. It
began with an alliance with Overlook Hospital in
1976 and now is approaching three quarters of a
million dollars provided annually to the group of
centers.
The Cooper Hospital/University Medical Center
program also has been able to initiate development
of a research laboratory with flow cytometry and
cytogenetics based on major contributions from
three separate nonprofit charities (Eagles Fly for
Leukemia, House of Kids, and the Canuso Foun-
dation) located in the Delaware Valley.
Without the largess of individuals and businesses
that contribute to these charitable organizations,
the citizens of New Jersey would find it necessary
to travel out of the state to avail themselves of expert
professionals to administer competent, state-of-the-
art care to their children who develop cancer. ■
REFERENCES
1. Cancer Facts and Figures — 1990. American Cancer
Society publication.
2. Deasy-Spinetta P, Spinetta JJ: Educational issues
for children with cancer, in Pizzo PA, Poplack DG (eds):
Principles and Practice of Pediatric Oncology. Philadel-
phia, PA, JP Lippincott Co., 1989, pp. 1027-1035.
3. Young JL, Ries LG, Silverberg E, et al.: Cancer in-
cidence, survival, and mortality for children younger than
15 years. Cancer 58:598-602, 1986.
4. Meadows AT, Krejmas NL, Belasco JB: The medical
cost of cure: Sequelae in survivors of childhood cancer, in
VanEys J, Sullivan MP (eds): Status of the Curability of
Childhood Cancers. New York, NY, Raven Press, 1980, pp.
263-276.
5. Pizzo PA, Poplack DG (eds): F*rinciples and Practice
of Pediatric Oncology. Philadelphia, PA, JP Lippincott
Co., 1989, chapters 41-43.
930
NEW JERSEY MEDICINE
Surfactant
Replacement Therapy
JEFFREY R. GREENWALD, MD
I. MARK HIATT, MD
THOMAS HEGYI, MD
The field of neonatology has experienced exceptional growth in recent years,
and several excellent facilities exist in New Jersey for the care of premature
and sick newborn infants. This article describes important advances made
in the management of neonatal respiratory distress syndrome.
Avery and Mead presented evidence that in-
fants dying with hyaline membrane disease
(HMD) were deficient in a material respon-
Drs. Greenwald (top), Hiatt
(bottom, left), and Hegyi (bot-
tom, right) are affiliated with
the Division of Neonatology,
Department of Pediatrics, St.
Peter’s Medical Center and
UMDNJ-Robert Wood John-
son Medical School, New
Brunswick. Requests for re-
prints may be addressed to
Dr. Hiatt, St. Peter's Medical
Center, 254 Easton Avenue,
New Brunswick, NJ 08901.
sible for lowering surface tension in the air passages
of the lung.1 The existence of this surface active
material or surfactant was reported by Pattle and
Clements in the early 1950s and its role in main-
taining lung volume at end-expiration was demon-
strated in the normal lung.2 Since this discovery,
physicians caring for premature infants have en-
visioned treating respiratory distress syndrome
(RDS) with surfactant replacement therapy.
The incidence of RDS varies inversely with ad-
vancing gestational age, occurring in approximately
20 percent of infants born before 36 weeks’ gestation
and in approximately 70 percent of infants born
before 30 weeks’ gestation.3 The total number of
cases of RDS in the United States is estimated to
be between 50,000 and 100,000 each year, with a 10
percent mortality. The morbidity from RDS is much
more extensive due to complications of therapy and
the impact of prematurity. Current therapy for mod-
erate to severe RDS includes high oxygen concentra-
tions and mechanical ventilation that cause short-
term complications such as pulmonary interstitial
emphysema (PIE) and pneumothorax (PTX), as
well as long-term complications like broncho-
pulmonary dysplasia (BPD). Other nonrespiratory
VOL. 87— NUMBER 11 NOVEMBER 1990
931
Prematurity Perinata^asphyxia
► Reduced surfactant synthesis, storage, and release
Decreased alveolar surfactant
Increased alveolar surface tension
Atelectasis
^ \
Uneven V/Q Hypoventilation
\ /.
Hypoxemia ^C02 retention
Acidosis
Pulmonary vasoconstriction
Pulmonary hypoperfusion
Capillary endothelial damage
Plasma leak
Fitlrin
Diffusion
gradient
Figure 1 . Pathogenesis of RDS.
complications include patent ductus arteriosus
(PDA), necrotizing enterocolitis (NEC), and in-
traventricular hemorrhage (IVH). The goal of new
therapy for RDS would be to reduce mortality and
to reduce the morbidity in the survivors.
WHAT IS RDS?
The pathology of RDS is characterized by diffuse
atelectasis and the formation of a membrane that
lines the visible air spaces. This membrane consists
of a fibrinous matrix of materials derived from the
blood and contains cellular debris derived from in-
jured epithelium. Clinically, the infant with RDS
will manifest symptoms either immediately after
birth or within two or three hours of age. These
symptoms include tachypnea and/or dyspnea mani-
fested by the use of the accessory muscles of breath-
ing, as well as expiratory grunting and flaring of the
alae nasi. Eventual respiratory fatigue leads to res-
piratory failure requiring mechanical ventilation.
Hypoxemia usually is present from the onset requir-
ing supplemental oxygen. Radiographic ab-
normalities include underinflation, symmetrical
haziness, and atelectasis. The “ground glass” ap-
pearance, the radiographic expression of such atelec-
tasis, is characterized by fine reticulogranular
opacities with prominent air bronchograms. The
most severe form of RDS will reveal a generalized
“white out” of the lung fields/'
Pulmonary function is abnormal with decreased
functional residual capacity (FRC) and decreased
lung compliance. There also is increased dead space
leading overall to a low effective tidal volume. The
pathophysiology of these clinical manifestations be-
gins with prematurity and its associated deficiency
of surfactant. Figure 1 reveals the chain of events
beginning with an increase in alveolar surface ten-
sion owing to decreased alveolar surfactant. In turn,
this leads to diffuse atelectasis and results in hypox-
emia, hypercapnia, and acidosis. A second phase of
RDS then ensues with pulmonary vasoconstriction
and hypoperfusion as well as capillary endothelial
damage and plasma leak leading to pulmonary
edema. This results in an increased diffusion gra-
dient that will worsen the ventilation parameters.
The time course of this schema generally is about
48 to 72 hours and during this time the infant is
extremely ill and requires extensive support. After
about 72 hours of age, recovery may start to be
evident with regeneration of alveolar type II cells
and an increase in surfactant synthesis.3
WHAT IS SURFACTANT?
Surfactant is a generic term for any material
found in the lung with properties to lower surface
tension at the air-water interface such as is seen in
the alveoli.4 In the human, surfactant is manufac-
tured by the type II pneumocytes between 24 and
28 weeks’ gestation. This process occurs at the same
time as alveolarization of the distal saccules in the
fetal lungs, providing the structure for respiration to
occur. A third fetal respiratory development that
occurs at this gestation is the production of the
alveoli-capillary unit owing to the proximity of the
pulmonary capillary bed to the potential air spaces
and alveolar lining cells. This forms the anatomic
932
NEW JERSEY MEDICINE
basis for respiratory function and is vital for ex-
trauterine air exchange. The three processes have
completely matured in the term fetus; therefore, be-
tween 24 weeks and term, respiratory support often
is needed.
Surfactant, as determined by animal and human
lung washings, contains a complex association of
phospholipids, proteins, and carbohydrates. The
major phospholipid that has been found in lung
washings is dipalmitylphosphatidylcholine (DPPC).
DPPC has very strong surface tension lowering
properties and comprises about 50 percent of the
surfactant complex. Other phospholipids include
phosphatidylinositol, phosphatidylethanolamine,
and phosphatidylglycerol (PG). In all, phospholipids
make up about 80 percent of the surfactant complex.
MAP (cm H20)
Figure 2. Exogenous surfactant administration:
MAP responses.
-10 1 6 12 24
TIME (hours)
Figure 3. Exogenous surfactant administration:
FIOj responses.
Another 10 percent of the complex is made up of
neutral lipids, such as cholesterol and the remaining
10 percent is made up of protein. It is interesting to
note that lung washings do not contain carbohy-
drates despite the fact that Scarpelli demonstrated
they are integral components of the surfactant sys-
tem in situ.5
There are three specific proteins identified in the
surfactant complex along with albumin and
globulin. SP-A is a high molecular weight protein
that binds rapidly to phospholipids and, in the pres-
ence of calcium, forms large lipid-protein ag-
gregates. This is the so-called “tubular myelin” that
is the three-dimensional structure of surfactant. SP-
B and SP-C are low molecular weight proteins and
are extremely hydrophobic. These substances are
more appropriately classified as proteolipids because
of their rapid association with lipids in the surfac-
tant complex. All three proteins are vital for full
surfactant activity. They are important in main-
taining the three-dimensional structure and they are
involved in spreading and re-uptake properties.6
The surface tension lowering properties of surfac-
tant can be demonstrated in vitro on a Wilhelmy
balance.7 This change in surface tension is analogous
to a force that counteracts the pressure exerted on
the alveoli to collapse during expiration. The elastic
properties of the lung provide this collapsing pres-
sure and usually there is a force provided by chest
wall tension that counteracts this pressure leading
to a functional residual capacity (FRC). In the
premature infant, however, the chest wall’s com-
pliance leads to chest wall collapse and a reduction
in FRC. The patency of the alveolus is further com-
promised, owing to LaPlace’s law of collapsing
spheres: P = kT/r. P is the collapsing pressure and
it is directly proportional to T, the surface tension
and indirectly proportional to r, the radius of the
sphere. If the surface tension was equal in all the
alveoli (potential sphere), then the smaller alveoli
would experience the most collapsing pressure. How-
ever, the presence of surface active material reduces
surface tension and maintains alveolar stability on
expiration.
DPPC alone significantly will lower surface ten-
sion in vitro, but not as much as pure surfactant.
In vivo, surfactant influences respiratory function;
it improves lung compliance and decreases the work
of breathing. Pulmonary function measurements
have demonstrated that RDS is a disease of low
compliance, with anatomical correlates of severe
atelectasis and pulmonary edema. Treatment with
surfactant ameliorates these problems by increasing
alveolar stability. Surfactant therapy also provides
a more uniform alveolar recruitment on inspiration
and decreases the driving force leading to pulmonary
edema.7
VOL. 87— NUMBER 11 NOVEMBER 1990
933
The biophysical properties necessary for an ex-
ogenous surfactant are empirical and include the
ability to lower surface tension on dynamic com-
pression; the ability to respread after dynamic com-
pression past monolayer collapse; the ability to ab-
sorb well from subphase to interface; and the ability
to vary surface tension during dynamic compression-
expansion.7 These properties provide the basis for in
vivo dynamic function and are vital for any form of
surfactant replacement therapy.
SURFACTANT REPLACEMENT THERAPY
The first experiments with surfactant replacement
were conducted in the 1960s using the most simple
form of surfactant. Chu and Robillard used aero-
solized DPPC instilled by nebulization into the
lungs of premature infants. These efforts were un-
successful in treating RDS and, in fact, these fail-
ures stalled the research for almost a decade. In the
early 1970s, however, Enhorning and Robertson
demonstrated improvement in pulmonary mech-
anics with the use of whole surfactant complex re-
placement therapy in premature rabbits. There-
after, multiple animal studies confirmed their re-
sults that set the stage for further use in human
infants.2,7,8
The whole surfactant complex obtained by cen-
trifugation of animal (mainly bovine) lung washings
contained a moderate amount of heterogenous pro-
teins (10 percent). Clinicians feared that this
amount of foreign protein when instilled into the
infant could produce a potential immunologic reac-
tion. Extraction strategies were developed and
Fujiwara was successful in retaining most of the
phospholipid with only 1 to 2 percent of the protein.
In 1980, Fujiwara used lipid extract of bovine lung
combined with DPPC and PG. This mixture was
successful in improving blood gases, lowering mean
airway pressures, and lowering inspiratory 02 con-
centrations within hours of treatment in ten infants
suffering from RDS.8 This mixture was administered
as a saline suspension via the endotracheal tube in
a preparation consisting of 100 to 150 mg of lipid per
kg and it became the basis of the commercially
produced surfactant TA that presently is being dis-
tributed by Abbott laboratories as Survanta® in a
research IND protocol.
Other types of surfactants also have been tried
and have met with success. In 1983, Hallman
avoided foreign proteins altogether by using human
surfactant obtained from pooled amniotic fluid.
Theoretically, human surfactant should be the best;
however, it is very difficult to mass produce this
product on a commercial basis. Many samples of
amniotic fluid are required to obtain enough pure
surfactant for one infant. Another strategy to avoid
foreign proteins has led to the use of completely
artificial surfactant. Bangham and Morley produced
a mixture of 70 percent DPPC and 30 percent PG,
calling it artificial lung expanding compound
(ALEC). Research still is being carried out with this
mixture, but it may yield the same results as pure
DPPC, since it is felt that the protein plays an im-
portant function. 2,7,8
The most recent development has been the pro-
duction of another artificial compound called Ex-
osurf®, presently being distributed by Burroughs-
Wellcome in a research IND protocol. This com-
pound was developed by Clements in San Francisco
and contains a mixture of DPPC and two alcohols.
These additives, tyloxapol and hexadecanol, are
spreading agents or emulsifiers that have been
shown to improve the activity of the synthetic mix-
ture.2
The mid-1980s have been the era of randomized
clinical trials with the different types of surfactants.
The results of several studies are presented in Table
1. There are two basic types of studies on the effect
of surfactant. The first type uses surfactant in a
prophylactic or preventive mode, attempting to give
surfactant as soon as possible after delivery. The
second type is the rescue mode, treating only those
infants who have severe RDS requiring intubation
and high oxygen concentrations. Early preventive
treatment is a compelling option, but many infants
are treated unnecessarily in this approach.
THE PRESENT THERAPY
At St. Peter’s Medical Center, New Brunswick, we
began using Exosurf® for therapy of RDS in Septem-
ber 1989. The protocol has very strict enrollment
criteria; some infants with RDS do not qualify for
treatment. The rescue therapy protocol that we have
adopted is such that the patient population needs
to fit the following criteria: a) birth weight greater
than 700 grams; b) 2 to 24 hours of age at first
dosage; c) diagnosis of RDS (surfactant deficien-
cy)— clinical criteria, radiologic criteria, or
biochemical criteria (fetal lung maturity screen); d)
intubated and on mechanical ventilation; e) arterial/
Alveolar (a/A) oxygen tension ratio less than 0.22;
f) parental/guardian informed consent obtained
prior to treatment; and g) exclusions: proven fetal
pulmonary maturity and congenital anomalies. This
protocol has been approved by the investigational
review board of St. Peter’s Medical Center and all
infants who met the above criteria were entered into
the study.
The medication is supplied as a lyophilized pow-
der reconstituted with sterile water making a
homogenous suspension. A dosage of 5 ccAg is ad-
ministered via a special endotracheal tube adapter.
During this time the infant remains on the ventilator
and is continuously monitored by both pulse oxi-
I
la
Da
19
19
19
19
Bl
Si
‘l
Ti
Di
Di
E;
l(
P
P
E
li
I
F
i
934
NEW JERSEY MEDICINE
Table 1. Placebo-matched controlled studies.
Date
Reference
Surfactant
1985
Enhorning
BLSE
Shapiro
CLSE
Kwong
CLSE
Wilkinson
DPPC/PG
Hallman
Human
1986
Merritt
Human
1987
Gitlin
Surf. TA
Fujiwara
Surf. TA
Morley
DPPC/PG
1988
Lucey
Surf. TA
1989
Burroughs- Wellcome*
Exosurf®
Burroughs- Wellcome*
Exosurf®
BLSE
— bovine lung surfactant extract
Surf.
TA— surfactant TA
’Unpublished studies
Table 2. Study results.
Demographics (n = 28)
Birth weight (grams +/- standard deviation)
1247 +/- 457
(Range in grams)
720-2270
Gestational age (weeks +/- standard deviation)
29 + /- 3
(Range in weeks)
24-34
Dose age (hours +/- standard deviation)
7.5 +/- 5.3
(Range in hours)
2-23
Extubation age (days +/- standard deviation)
8.5 +/- 10.4
(Range in days)
1-50
Outcome
Mortality: 6
Morbidity (n = 22)
Patent ductus arteriosus: 20
Pulmonary interstitial emphysema/pneumothorax: 7
Bronchopulmonary dysplasia: 12
Intraventricular hemorrhage: 9 (6 with grade 3-4)
Necrotizing enterocolitis: 2
Retinopathy of prematurity: 4
metry and transcutaneous 02 and C02 sensors. The
infant is positioned in a specified manner to dis-
tribute the Exosurf® homogenously.
A second dose usually is given 12 hours after the
first dose, but this dose is held if the infant has
improved to the point of extubation. The nurse
monitors infant vital signs prior to instillation and
at several intervals during instillation. The respira-
tory therapist is available to make ventilator
changes as directed by the physician administering
Mode
Prophylactic
Prophylactic
Prophylactic
Prophylactic
Rescue
Prophylactic
Rescue
Rescue
Prophylactic
Rescue
Rescue
Prophylactic -
CLSE— calf lung surfactant extract
Human— amniotic fluid extract
the surfactant . All other aspects of routine care, such
as fluid therapy, thermoregulation, and glucose
homeostasis are maintained throughout adminis-
tration.
In order to study the effect of surfactant adminis-
tration, we have obtained pulmonary function
measurements prior to administration and then at
specified intervals after therapy. Our methods for
measuring pulmonary functions in the neonate, the
PeDS system, is widely used in newborn intensive
care nurseries.9 A neonatal pneumotachometer, con-
nected between the endotracheal tube and the ven-
tilator tubing, measures flow. Tidal volume is ob-
tained by integrating this flow. A differential pres-
sure transducer, connected to a balloon in the in-
fant’s lower esophagus, measures esophageal pres-
sure, a close estimate of intrapleural pressure. The
transducer also measures airway pressure. The dif-
ference between these two pressures yields the trans-
pulmonary pressure used to calculate pulmonary
compliance and resistance by the PeDs system.
The PeDs system is a computerized program (dis-
tributed by Medical Association Services, Inc.) that
estimates a best fit from the data and plots flow-
volume, pressure-volume, and scalar curves. A
printout is obtained of all these curves as well as an
overall formulation of the data.
In Table 2, we present the results of our data on
the first 28 patients. The dose age is the age of the
infant when the first dose of surfactant was given (all
attempts were made to give the medication as soon
as the infant fit all criteria). The extubation age is
the age of the infant when positive pressure ventila-
tion no longer was necessary and the endotracheal
tube was removed. In our unit, it is standard therapy
to place infants on nasal CPAP after being ex-
tubated to prevent postextubation atelectasis. Only
one of the infants required reintubation; this was
Results
Improvement
Moderate
Improvement
Negligible
Improvement
Improvement
Improvement
Improvement
Mild
Reduced Severity
Reduced Severity
Reduced Severity
VOL. 87— NUMBER 11 NOVEMBER 1990
935
01 (cm H20)
14 r
12 -
2 I l I l I
-10 1 6 12 24
Figure 4. Exogenous surfactant administration:
01 responses.
AaD02 (mm Hg)
Figure 5. Exogenous surfactant administration:
AaD02 responses.
due to postextubation stridor. Twelve infants de-
veloped bronchopulmonary dysplasia (BPD) and re-
quired oxygen therapy for more than 28 days, but
only one of these infants required ventilation for
more than three weeks. All of the infants were off
supplemental oxygen prior to discharge.
Four of the six infants who died suffered from
severe perinatal asphyxia at birth. One infant died
from E. coli sepsis and the other death was in an
extremely premature infant (gestational age of 24
weeks, birth weight of 720 g), who probably had
pulmonary immaturity in addition to RDS. With
respect to short-term morbidity, it is interesting to
note that 20 of the infants had PDA, defined as
echocardiographic evidence of a left to right shunt
through the ductus arteriosus. Our standard
protocol includes early echocardiography and early
treatment of the PDA with indomethacin. This ap-
proach hopes to avoid the complications of a PDA
and is the recommendation of Burroughs-Wellcome.
Other major short-term complications still are
seen such as PIE and PTX. It is interesting to note
that the incidence of these complications is no dif-
ferent than prior to surfactant therapy. Certainlj ,
barotrauma still is a major hazard and it may bt
even more dangerous during a sudden improvemeni
in pulmonary compliance that can occur after sur
factant administration. In fact, our early experience
led us to decrease mechanical ventilation almosl
immediately after therapy. This reduction ir
barotrauma yielded a decreased incidence of PIE
and PTX. The ability to lower mean airway pressure
(MAP) is demonstrated in Figure 2.
We analyzed several other parameters during the
course of surfactant therapy and these are shown ir
Figures 3, 4, and 5. The benefit of Exosurf® in re-
gards to alveolar to arterial oxygen gradient
(AaD02) and oxgenation index (01), as well as the
reduction in Fi02 is demonstrated. There is a great
improvement within 6 hours after the first dose oi
Exosurf® and then a leveling off of the change there-
after. There actually may be a worsening after the
second dose of Exosurf® since the expected rate of
improvement decreases so rapidly. We must re-
member, however, that these infants still are in their
first 24 to 36 hours of life. In the typical course of
RDS, the infants worsen at this time with pro-
gressive atelectasis and pulmonary edema prior to
recovery. However, with surfactant therapy, these
infants are improving rather than deteriorating.
The acute benefit, however, does not necessarily
prevent the infant from suffering some of the other
consequences of prematurity such as NEC, IVH, or
retinopathy of prematurity (ROP). These three com-
plications occurred in the sickest and smallest in-
fants and may be totally independent of the course
of the infants’ respiratory distress.
There have been several reports of the changes of
pulmonary function with surfactant administration,
using other formulations and not Exosurf®. In gen-
eral, these reports have demonstrated an improve-
ment in pulmonary compliance in surfactant-
treated patients versus controls, but these improve-
ments do not appear to be immediate. This result
may be related to an overventilation inherent in
mechanical ventilation such that the measurements
are skewed to the overdistention part of the volume-
pressure curve. Therefore, any improvement in com-
pliance might be masked. Mechanical ventilation,
unfortunately, is not as perfect as natural ventila-
tion and higher pressures sometimes are needed to
provide the same effective volume. Indeed, those
infants given surfactant and being treated with
CPAP alone, did demonstrate fairly immediate im-
provements in compliance.10
We have not been able to demonstrate immediate
improvements in compliance in our measurements.
However, our impression in a majority of the infants
is that a clinical response occurs within one hour of
administration. Observation of chest expansion after
936
NEW JERSEY MEDICINE
Jl
surfactant administration yields revealing infor-
mation that has not yet been corroborated by our
measurement of pulmonary function.
Despite the fact that significant changes in
pulmonary compliance could not be demonstrated
acutely, the majority of studies on surfactant re-
placement have demonstrated an overall improve-
ment in mortality rate for low birth weight infants.
In our unit, the mortality rate for infants 700 to 2,000
g is less than 5 percent. The smallest infants ex-
perience the highest mortality rate with infants less
than 700 g having a mortality rate of 80 percent.
Infants between 700 and 1,000 g experienced a mor-
tality rate of 20 percent and then the rate dropped
to 1 percent. Therefore, it is difficult to make con-
clusions about the effect of surfactant on mortality
rate without a controlled trial. Likewise, for analysis
of morbidity, a controlled, prospective study is
necessary. There are several observations, however,
that we feel can help us to formulate further studies
with Exosurf®.
As was cited previously, the response to the first
dose of surfactant is fairly dramatic, whereas after
the second dose, 12 hours later, there actually may
be a worsening of the infant’s condition. It is possible
that this second dose may be too much fluid for the
now open alveoli to handle. The first dose is given
presumptively when there is diffuse alveolar collapse
and it is assumed that as the surfactant is spread
throughout the airways, the alveoli start to expand
and ventilation is improved. The second dose is
given at a time when there already has been signifi-
cant improvement and the infant probably has
started to produce a significant amount of natural
surfactant. The other possibility is that there is less
uniformity of the atelectasis at the time of the sec-
ond dose, such that some regions of the lung receive
more surfactant than others. In either case, the
amount of fluid from this second dose may be harm-
ful. It is interesting to note that when Exosurf® is
given prophylactically within 30 minutes of birth,
there are no subsequent doses in the Burroughs-
Wellcome protocol. Since infants are born with
fluid-filled lungs, it is presumed that early adminis-
tration will result in more efficient distribution. In
fact, in a subset of our infants, early administration
was associated with the most rapid improvement.
These may be the infants who will not benefit from
a second dose. It, therefore, would be of value to
perform a study withholding the second dose.
Further analysis on the timing of administration also
would be important.
Long-term followup studies have been undertaken
and data are being collected to determine the effects
associated with surfactant replacement therapy. To
date, no serious complications have been attributed
to therapy; however, some institutions are finding
that since the infants are getting off the ventilator
quicker, they tend to manifest symptoms of apnea
of prematurity sooner. This may or may not con-
tribute to long-term morbidity.
Our recommendation at this time to the families
of premature infants with RDS is that they consent
for surfactant therapy to be included in the thera-
peutic regimen of their infants. There have been over
5,000 infants nationwide who have received Exosurf®1 2 3 4 5 6
and the data are encouraging. Ideally, the preven-
tion of prematurity and RDS should be our ultimate
goal. Since this aim is unreachable at least in the
forseeable future, our challenge is to treat the prob-
lems of prematurity with the best possible therapy
of today that includes surfactant replacement.
CONCLUSION
There are several important aspects of surfactant
replacement to be studied. Controlled studies com-
paring the different types of surfactant need to be
undertaken in a multi-institutional fashion to enroll
as many infants as is necessary to reach acceptable
conclusions. New and better types of surfactants will
be available in the future, such as genetically engi-
neered surfactant. Questions regarding timing of ad-
ministration and amount of these drugs need to be
further analyzed. ■
REFERENCES
1. Avery ME, Mead J: Surface properties in relation to
atelectasis and hyaline membrane disease. AJDC
97:517-523, 1959.
2. Shapiro D: The development of surfactant replace-
ment therapy and the various types of replacement surfac-
tants. Seminars Perinatol 12:174-179, 1988.
3. Fanaroff AA, Martin RJ: Neonatal Perinatal Medi-
cine, Disease of the Fetus and Infant. Philadelphia, PA,
C.V. Mosby Company, 1987, pp. 580-589.
4. Notter R: Biophysical behavior of lung surfactant:
Implications for respiratory physiology and patho-
physiology. Seminars Perinatol 12:180-212, 1988.
5. Jobe A: Surfactant and the Developing Lung ,
Neonatal Pulmonary Care. Philadelphia, PA, Appleton-
Century-Crofts, pp. 75-99.
6. Weaver TE, Whitsett JA: Structure and function of
pulmonary surfactant proteins. Seminars Perinatol
12:213-220, 1988.
7. Notter RH. Shapiro DL: Lung surfactants for re-
placement therapy: Biochemical, biophysical, and clinical
aspects. Clinics Perinatol 14:433-478, 1987.
8. Vidyasagar D, Shimada S: Pulmonary surfactant re-
placement in respiratory distress syndrome. Clinics Per-
inatol 14:991-1015, 1987.
9. England SJ: Current techniques for assessing
pulmonary function in the newborn and infant: Advan-
tages and limitations. Pediatr Pulmonol 4:48-53, 1988.
10. Davis JM, Veness-Meehan K, Notter RH, et ah:
Changes in pulmonary mechanics after the administration
of surfactant to infants with respiratory distress syndrome.
N Engl J Med 319:476-479, 1988.
VOL. 87— NUMBER 11 NOVEMBER 1990
937
STATEMENT OF OWNERSHIP, MANAGEMENT,
AND CIRCULATION
(Required by 39 U.S.C. 3685)
1. Title of Publication: NEW JERSEY MEDICINE.
1A. Publication No.: 00257524.
2. Date of Filing: September 20, 1990.
3. Frequency of Issue: Monthly.
3A. No. of Issues Published Annually: 12.
3B. Annual Subscription Price: $35.
4. Location of Known Office of Publication: 2 Princess Road, Lawrenceville, Mercer County, NJ 08648.
5. Location of Headquarters or General Business Office of the Publisher: 2 Princess Road, Lawrenceville,
Mercer County, NJ 08648.
6. Names and addresses of publisher, editor, and managing editor: Publisher, Medical Society of New
Jersey, 2 Princess Road, Lawrenceville, NJ 08648. Editor, Howard D. Slobodien, MD, 2 Princess Road,
Lawrenceville, NJ 08648. Managing Editor, Geraldine R. Hutner, 2 Princess Road, Lawrenceville, NJ
08648.
7. Owner (if owned by a corporation, its name and address must be stated and also immediately
thereunder the names and addresses of stockholders owning or holding 1 percent or more of total
amount of stock. If not owned by a corporation, the names and addresses of the individual owners must
be given. If owned by a partnership or other unincorporated firm, its name and address, as well as
that of each individual must be given. If the publication is published by a nonprofit organization, its name
and address must be stated.): Medical Society of New Jersey, 2 Princess Road, Lawrenceville, NJ 08648
(a nonprofit corporation of New Jersey).
8. Known bondholders, mortgages, and other security holders owning or holding 1 percent or more
of total amount of bonds, mortgages, or other securities: None (a nonprofit corporation of New Jersey).
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only). The purpose, function, and nonprofit status of this organization and the exempt status for federal
income tax purposes have not changed during preceding 12 months.
10. Extent and nature of circulation:
A.
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C.
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Average
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no. copies
of single
no. copies
issue
each issue
published
during
nearest
preceding
to filing
Extent and nature of circulation
12 months
date
Total no. copies printed (net press run)
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Paid circulation
1. Sales through dealers and carriers, street vendors,
and counter sales
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Free distribution by mail carrier or other means — samples,
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shown in A)
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and complete.
(signed) Arthur White
Director of Finance and Administrative Services
12. For completion by publishers mailing at the regular rates (Section 132.121, Postal Service
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the publication named in item 1 at the phased postage paid rate presently authorized by 39 U.S.C. 3626.
I
i
ii
L
a
!'
[
NEW JERSEY MEDICINE
938
NOTEBOOK
■ TRUSTEES’ REPORT ■
A meeting of the Board of
Trustees was held on September
16, 1990, at the executive offices in
Lawrenceville. Detailed minutes
are on file with the secretary of
your county society; a summary of
significant actions follows.
Report of the President . . .
(1) Appointments: Noted the fol-
lowing appointments: Dr. Fred M.
Palace as MSNJ representative to
the Board of the New Jersey Hos-
pital Association; Dr. Louis L.
Keeler as MSNJ Board representa-
tive to the Academy of Medicine of
New Jersey Board of Trustees; and
Dr. Edward A. Schauer as chair-
man of the Committee on Long-
Range Planning and Development.
Report of Executive Director . . .
(1) MSNJ Financial Statements
. . . Reviewed and approved the
financial statements for the
periods ending June 30 and July
31, 1990.
(2) Litigation: Noted the follow-
ing: argument on the medical
malpractice surcharge case
(MSNJ versus Merin) will be
heard in the appellate division in
September; oral argument in the
tax court for this case (MSNJ is
challenging three aspects of the no-
fault law: the $100 license charge,
the mandated fee schedule, and a
ban on balance billing) has been
delayed.
(3) Regulatory Activity . . . Re-
ceived copies of Judge Stern’s com-
ments regarding the physician as-
sistants proposal (page 769 of
NEW JERSEY MEDICINE) and
MSNJ’s response to the medical
fee schedule rule (page 767 of
NEW JERSEY MEDICINE); and
Mr. Maressa noted that until the
fee schedule is adopted, physicians
should bill at their usual rates.
(4) NJ State Medical Under-
writers, Inc. (NJSMU) . . . Was
notified that Judge Stern has been
retained as legal counsel concern-
ing the no-fault surcharge being
assessed all casualty insurance
companies in New Jersey, and ap-
proved a bylaw change for the title
of the president of NJSMU to be-
come “president and chief ex-
ecutive officer.”
(5) Medicare . . . Noted the fol-
lowing: progress has been made on
the issue of assistants at surgery
with Dr. Ian Samson as the desig-
nated speaker on the topic; ap-
proval is to be given for an assis-
tant at appendectomies as well as
a number of procedures on Penn-
sylvania Blue Shield’s medical
necessity list; Pennsylvania Blue
Shield mailed 2,600 MAAC ex-
ceeder letters and 2,200 physicians
have appealed; and unique physi-
cian identifier numbers (UPIN)
will be reissued via a general mail-
ing to physicians.
(6) New Jersey State Depart-
ment of Health Licensing Stan-
dards for Hospitals . . . Approved
the following recommendation:
That Rule 8:43G-12.5, under Sub-
chapter 12 — Emergency Department,
of the New Jersey State Department of
Health Licensing Standards for Hospi-
tals, reads as follows:
There shall be a physician specialist on
call to the emergency department for
each major clinical service provided by
the hospital. On-call physicians shall
be able to arrive within 30 minutes
after being summoned for a critical
case, under normal transportation con-
ditions.
UMDNJ Report . . . Publicized a
walkathon in New Brunswick
sponsored by University Cham-
pions to benefit HIV positive
women and children and a march
in New Brunswick sponsored by
the Hyacinth Foundation to help
AIDS victims physically and
financially; and noted a 15 percent
increase in tuition for medical and
dental students and a tuition in-
crease approaching 35 percent for
allied health programs.
NJ Hospital Association . . .
Noted the following: the Maternal
Outreach and Managed Services
program (MOMS) was tabled by
the Health Care Administration
Board due to concerns about fund-
ing; a representative of NJHA will
be invited to discuss uncompen-
sated care at the next meeting of
the Council on Public Relations;
comments on the Governor’s Com-
mission report will be forthcoming.
Audit Review Committee . . . Ap-
proved the following recommen-
dations:
That the audited financial statements
be accepted and a copy thereof be for-
warded to each component society.
That Ernst & Young be continued as
the external auditors.
Task Force on the Shortage of
Nurses and Technical Personnel
. . . Approved the following rec-
ommendations:
That members of MSNJ be urged to:
Distribute and make available in their
offices, hospitals, and clinics, pam-
phlets and brochures concerning ca-
VOL. 87— NUMBER 11 NOVEMBER 1990
939
reers and educational programs in the
allied health professions. (Such pam-
phlets are available from NJHA Nurs-
ing and Allied Health Resource
Center.) Make informed educational
referrals for students, patients, and
others where appropriate toward ca-
reers in the allied health professions.
Participate in and support the allied
health educational programs in their
area. Support legislation for allied
health programs in New Jersey.
Support appropriate salary levels for
allied health professionals. Include the
allied health professional in an ap-
propriate level of discussion concern-
ing patients and procedures. Respect
the allied health professional as an es-
sential and endangered member of the
health care team.
Also, discharged the Task Force on
the Shortage of Nurses and Tech-
nical Personnel and MSNJ will
provide representatives to ap-
propriate organizations for medical
input; expressed appreciation to
Doctor Madara and the Task
Force.
Senior Citizens Task Force . . .
Approved the following recommen-
dation and directed that it be re-
ferred to the Council on Public Re-
lations for implementation:
That MSNJ provide posters to phy-
sicians announcing that the office
participates in the Senior Medical
Courtesy Program, similar to the
poster used by the Union County
Medical Society.
Task Force on AIDS . . . Ap-
proved the following recommen-
dations:
That the Board of Trustees approve
the New Jersey Hospital Association
Comprehensive AIDS/HIV Legislation
with the changes suggested by MSNJ’s
Task Force on AIDS.
That the Board of Trustees retain its
position as stated in “AIDS: Infor-
mation for Physicians” under “Medi-
cal Society of New Jersey Policy on
AIDS— HIV Testing.”
That the Board of Trustees establish a
dialogue with the New Jersey State
Department of Health to work toward
the elimination of the Department of
Health recommendation that a special
consent form be used to test for HIV.
Testing should be performed when it is
clinically indicated without inter-
ference or obstruction.
Unfinished Business . . . Noted
the following items: Tax Deduc-
tions for Uncompensated Care
(Resolution #15): accepted the re-
sults of the study to determine
what type of patient is the most
likely to sue a doctor; Dr. James E.
George stated that it would be an
unwise expenditure of time and re-
sources to attempt to prove the
thesis that uncompensated care
cases or indigent cases in fact are
a medicolegal hazard for physi-
cians; HIV Testing for Hospital
Admissions (Resolution #27E): re-
ferred this resolution to the Task
Force on AIDS for determination
as to whether or not the Society
should seek legislation to imple-
ment the intent of the resolution
(all hospital admissions have HIV
testing); HIV Infection as a Com-
municable Disease (Resolution
#1): referred this resolution (call-
ing for MSNJ to adopt that policy
that states HIV infection be con-
sidered as any other reportable
communicable disease, and pa-
tients be treated accordingly) to
the Task Force on AIDS. □
■HUMDNJ NOTES HI
Computer Program Replaces
Pathology Lectures. Second-year
medical students at UMDNJ-Rob-
ert Wood Johnson Medical School
are using a customized computer
software program-developed at
the school — to learn pathology, the
study of the nature, and cause of
diseases. Two major elements have
replaced the lecture format for
teaching pathology at the school:
the software/video disk and twice-
a-week small-group study sessions.
Dr. Robert Trelstad, chairman of
the Department of Pathology, and
Dr. Jana Raskova, professor of
pathology, are the architects of
this program that gives students
more time to talk with professors
to get information clarified and in-
terpreted.
The computer software program,
incorporating the pathology text-
book and a base of 5,000 questions,
was developed by Dr. Trelstad,
who selected 1,500 images from a
26,000-based video disk developed
by the University of Utah Medical
School in Salt Lake City.
Special Dental Clinic To Open
in Camden. A dental clinic for pa-
tients with AIDS and other infec-
tious diseases, operated by
UMDNJ-New Jersey Dental
School, will open soon. Located at
221-223 South Sixth Street,
Camden, the clinic is similar to the
LIMDNJ Special Services Dental
Clinic in Newark, that also treats
infectious disease patients. The
clinics are the only state-funded,
public dental facilities of the kind
in New Jersey. Dr. Talib Najjar,
professor of oral and maxillofacial
surgery, will direct the clinic. It
also will be staffed by dental school
faculty and postdoctoral students.
The treatment clinic also will
serve as a research facility for
AIDS.
State Assembly Commends
Sickle Cell Centers. The New Jer-
sey General Assembly has adopted
a resolution commending UMDNJ
for its operation of Sickle Cell
Centers in southern New Jersey to
serve adults with the disease. The
resolution, presented by Assembly
Majority Leader Wayne R. Bryant
(D-5th Dist.), cited the establish-
ment of Centers in Camden and
Stratford “as part of the Univer-
sity of Medicine and Dentistry of
New Jersey’s commitment to
provide health care services to the
medically indigent residents of this
State.” The Centers were in-
stituted by UMDNJ-School of Os-
teopathic Medicine and its De-
partment of Medicine, Division of
Hematology/Oncology.
The resolution noted, “These
centers provide a comprehensive
health care program for adult sick-
le cell patients and their families
to provide an educational compo-
nent that encompasses the com-
munity, the patients, their fami-
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NEW JERSEY MEDICINE
lies, and their health care pro-
viders. Through these vital clinics,
UMDNJ is effectively addressing
one of the crucial health care con-
cerns of a significant minority
population of this state and par-
ticipating in the quest for a cure for
sickle cell diseases.” □ Stanley S.
Bergen, Jr., MD
■■MSNJ AUXILIARY ■■
Membership is increasing and
the Auxiliary is making every ef-
fort to maintain the trend into the
21st century. Success of the
challenge depends on two factors:
attracting and sustaining as mem-
bers the growing number of career-
oriented physicians’ spouses who
have a special expertise to con-
tribute to the Auxiliary but whose
degree of participation, or lack of
it, is engendered by unavoidable
time constraints, and the Aux-
iliary’s ability to become more flex-
ible in its operations and to focus
on the “newness” of the organiza-
tion in order to recruit spouses of
the increasingly large number of
female physicians. Auxiliary
leaders believe the addition of
male members could provide a di-
vergent point of view and in-
novative ideas— perhaps even a
change in the public’s conception
of the role of a medical auxiliary.
The Auxiliary’s recruitment
strategy involves making member-
ship convenient and personally re-
warding. Meetings are more
streamlined with no time w'asted
on lengthy programs or prolonged
social hours. Program topics are
planned to appeal to all segments
of the membership: male, female,
career-oriented, housewives,
widows, widowers, and resident
physician and medical student
spouse groups. Members may
choose their level of commitment
and support: for some this may
mean simply paying dues and for
others it may mean legislative lob-
bying, AMA-ERF fundraising, or
tending to community health
needs.
Regardless of commitment level,
the benefits of membership are
enormous. The Auxiliary offers
personal development through
leadership training and educa-
tional seminars and resources. The
professional skills development
(PSD) program, designed to turn
volunteer training into marketable
job skills, provides a central source
for documentation of members’
participation in instructional
courses, training programs, and
AMA Auxiliary leadership posi-
tions. All information is com-
puterized and readily available for
withdrawal when needed for career
opportunities. Publications such
as Facets and The Shingle are
provided to members on a regular
basis. The magazines are written
for and about physicians’ spouses
with current data on health legis-
lation as well as a wide range of
topics related to the medical pro-
fession and the medical family.
Available also are special dis-
counts on hotels, rental cars,
videocassettes, insurance, and in-
vestment services. Most impor-
tantly, however, the Auxiliary
provides fellowship — an oppor-
tunity to meet other physician
families, to share information, and
to discuss common concerns
through a nationwide network of
75,000 physicians’ spouses with
similar goals.
The Auxiliary urges MSNJ phy-
sicians to encourage spouses to be-
come part of this lifetime activity
and share the benefits of belong-
ing. □ Marion H. Geib
QUALITY OF
^■LIFE AND HEALTH ■■
A potential solution to the dual
problem of access and cost may be
an evolving broad-based consensus
in support of health care effective-
ness research. The Quality of Life
and Health Survey (QLHS) will
develop a standard instrument
that can be used in a variety of
settings to measure patient values
about treatment outcomes.
The Citizens’ Committee on
Biomedical Ethics (CCBE), a pri-
vate, nonprofit, grassroots or-
CANDIDATES FOR
MSNJ OFFICES
If you are interested in becoming an Officer,
Trustee, or member of the AMA Delegation, a new
opportunity exists for you.
The Nominating Committee is meeting to con-
sider candidates. The Committee will consider
members other than those recommended by coun-
ty medical societies and nominating delegates for
any of these offices.
If you wish to be considered, please contact your
county medical society or the Medical Society of
New Jersey for the necessary forms.
This is a real opportunity for grassroots can-
didate development and we urge you to use it.
VOL. 87— NUMBER 11 NOVEMBER 1990
941
ganization, is participating with
the University of Colorado Center
for Health Ethics and Policy in the
QLHS, funded by Pew Charitable
Trusts. The purpose of the project
is to develop an instrument that is
statistically reliable in measuring
the public and patients’ per-
ceptions about medical/surgical
treatment outcomes. The instru-
ment developed is framed entirely
from people’s perceptions about
problems in living, rather than by
reference to objective facts
gathered by others.
When evaluating health care
services on the basis of expected
benefit, it is necessary to utilize a
common language by which a
health benefit can be measured
and compared across different
types of interventions. This com-
mon language involves the impacts
of treatment on life expectancy
and quality of life. Judgments con-
cerning expected benefits of health
care must be based on a full range
of information bearing on the par-
ticular intervention for a specific
class of patients (or specific indica-
tions). There are three types of in-
formation: 1. physician estimates
about health outcomes based on
findings in the literature and on
medical experience; 2. information
from patients concerning per-
ceptions of the quality of life out-
comes of particular interventions;
3. societal values concerning
health outcomes associated with
the treatment.
A variety of biases exists in ask-
ing patients to make these judg-
ments. First, only living patients
can provide this information which
biases patient responses in favor of
the intervention. Second, patients
may tend to overestimate the ben-
efits realized from treatment in
order to justify their actions to
themselves. Again, this bias acts in
favor of the intervention. Third,
eliciting quality of life data only
from patients who elected to re-
ceive the interventions without
equal efforts to obtain similar in-
formation from patients who con-
sidered but declined to receive the
intervention, may obscure the ex-
tent to which any perceived quali-
ty of life improvements reflect a
significant improvement from
what would have occurred had the
intervention been foregone.
The QLHS asks patients about
the extent to which quality of life
is a problem for them.
This frame has been selected to
guard against potential use of in-
formation to judge someone else’s
quality of life for two reasons: ob-
jective functional data obtained in
most quality of life questionnaires
are useful for individual physician
and patient decision making but
such data do not necessarily relate
well to perceived quality of life and
not everybody is ready to accept
quality of life as a legitimate basis
for resource distribution decisions.
The entire potential patient
population is prospectively at risk
for ill health, and will or will not
have access to desired health care
depending on distribution de-
cisions. It seems appropriate,
therefore, that values of the gen-
eral citizenry be used for purposes
of resources distribution.
To analyze how society should
distribute resources, it is im-
perative that we include people’s
perceptions about the benefits and
burdens of treatments. This proj-
ect is a beginning effort to obtain
these perceptions by developing a
reliable questionnaire to gather
these perceptions. □ Theresa H.
Hauber, MPH
PLACEMENT FILE
MSNJ DIRECTORY
The following physicians have
written to the executive offices of
MSNJ seeking information on pos-
sible opportunities for practice in
New Jersey. The information has
been supplied by the physicians. If
you are interested in any further
information concerning these phy-
sicians, we suggest you make in-
quiries directly to them.
ANESTHESIOLOGY
Michael Silverberg, MD, 2020 Walnut
St., Apt. 29K, Philadelphia, PA 19103.
Yale 1983. Board eligible. Group or
hospital. Available July 1991.
CARDIOLOGY
George D. Birmingham, MD, 3531
Salerno Ct., Apt. 5, Middleton, WI
53562. Mount Sinai 1984. Board
eligible. Board certified (IM). Group or
partnership. Available July 1991.
INTERNAL MEDICINE
Anan Adnan Faidi, MD, 30 Charles St.
W, Apt. 1717, Toronto, Ontario, IM4Y
1R5 Canada. Jordan 1983. Board certi-
fied. Also, board eligible (ENDO-
CRIN). Group. Available.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner-
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible.
Group or hospital based. Available.
Data sheets for the 1991 Medical
Society of New Jersey Mem bership
Directory have been mailed to all
members. Please complete the
data sheets and return them in the
self-addressed, stamped envelope.
To be included in the 1991 Mem-
bership Directory, data sheets
need to be returned by November
15, 1990. If you have any questions,
please call Mrs. Joyce Guest, 609/
896-1766, at MSNJ headquarters.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Wood-
side Ave., Trenton, NJ 08618. Rutgers
1980. Board certified. Part time or full
time. Available.
SURGERY
Donna Vecchione, MD, 27700 Bishop
Park Dr., 4025, Willoughby Hills, OH
44092. SUNY-Stony Brook 1985.
Board eligible. Partnership, solo,
multispecialty group. Available.
UROLOGY
Ronald G. Frank, MD, 380 Rector PL,
Apt. 1 1 J, New York, NY 10280. New
York Medical 1985. Group or partner-
ship. Available July 1991.
942
NEW JERSEY MEDICINE
1
1991 MSNJ ANNUAL MEETING
The Board of Trustees of the Medical Society of New Jersey approved the Committee on
Annual Meeting’s recommendation that the 1991 Annual Meeting be held at the Trump Taj
Mahal Casino Resort in Atlantic City, on Sunday, April 28, through Wednesday, May 1, 1991.
The Merv Griffin’s Resorts Casino Hotel will participate with the headquarters hotel (Trump
Taj Mahal) for the 1991 Annual Meeting. The daily schedule follows:
Saturday, April 27, 1991
3:30 p.m. Board of Trustees’ Meeting
Sunday, April 28, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
10:00 a.m. Educational Programs
11:30 a.m. Exhibits Open
1:30 p.m. House of Delegates
3:30 p.m. Reference Committee Meetings
Monday, April 29, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates (Election)
12:00 noon Golden Merit Award Ceremony and Reception
2:30 p.m. Reference Committee Meetings
5:00 p.m. JEMPAC Political Forum
5:45 p.m. JEMPAC Wine and Cheese Reception
6:30 p.m. Union County Medical Society Reception
Tuesday, April 30, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Exhibits Open
9:00 a.m. House of Delegates
1:30 p.m. House of Delegates
7:00 p.m. Inaugural Reception and Dinner
honoring Doctor and Mrs. Joseph A. Riggs
Wednesday, May 1, 1991
8:00 a.m. Registration Opens
8:00 a.m. Message Center Opens
8:30 a.m. Educational Program
1:00 p.m. Board of Trustees’ Meeting
VOL. 87— NUMBER 11 NOVEMBER 1990
943
HOUSING APPLICATION
225th ANNUAL MEETING
THE MEDICAL SOCIETY OF NEW JERSEY
APRIL 28-MAY 1, 1991
Select the hotel of your choice. Mail the entire form with one night’s deposit to that hotel.
TRUMP TAJ MAHAL CASINO/RESORT (Headquarters Hotel)
1000 BOARDWALK AT VIRGINIA AVENUE, ATLANTIC CITY, NJ 08401
RESERVATION DEPARTMENT 1-800-825-8786
(Please Print)
Name
Address
City State Zip
Home Phone Business Phone
Sharing With
Date of Arrival Time
Date of Departure
Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the TRUMP TAJ MAHAL CASINO & RESORT or complete the following:
Card # Type Exp. Date
SCHEDULE OF RATES SUBJECT TO 13% TAX
□ SINGLE $135 □ DOUBLE $135 (Reservations must be received prior to March 29, 1991)
Extra Person $25
□ One-Bedroom Suite $275 per day
□ One-Bedroom Hospitality Suite $275 per day
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 5 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★
MERV GRIFFIN’S RESORTS CASINO HOTEL
NORTH CAROLINA AVENUE & BOARDWALK, ATLANTIC CITY, NJ 08401
RESERVATION DEPARTMENT 1-800-438-7424
(Please Print)
Name
Address
City State Zip
Home Phone Business Phone
Sharing With
Date of Arrival Time
Date of Departure Time
A one-night deposit (equivalent to room rate) is required with all reservation requests. Please send check or money
order payable to the MERV GRIFFIN’S RESORTS CASINO HOTEL or complete the following:
Card # Type Exp. Date
SCHEDULE OF RATES SUBJECT TO 13% TAX
□ SINGLE $89 □ DOUBLE $89 (Reservations must be received prior to March 29, 1991)
□ One-Bedroom Suite $255 □ Two-Bedroom Suite $340
Check-out time is 12 Noon. Rooms may not be available for check-in until after 3 p.m. Check-in time on Sundays
is 6 p.m. FORTY-EIGHT (48) HOURS NOTICE OF CANCELLATION is required for a full refund.
PARKING: FREE PARKING TO REGISTERED GUESTS. One car per room.
□ Check if Official Delegate County
944
NEW JERSEY MEDICINE
*
Mary Ann Hamburger is a Medical Management
Consultant and an EXPERT in CPT Codes
She can put your practice on the right
REIMBURSEMENT TRACK!
Sorting out third-party payment codes accurately and fairly is essential to
today's successful office practice • Mary Ann Hamburger Associates has
researched the CPT Codes and knows them thoroughly. Whatever your
specialty, she can help you obtain the best compensation for your services
• Setting a Fee Schedule appropriate to your specialty, your geographic
area and changing market conditions is the first step in a better billing
system • Mary Ann Hamburger Associates has the know-how and the
sensitivity to get this critical office function working at its best • State-of-
the-art office administration frees the physician to practice fine medicine
and keep up on the latest developments • Mary Ann Hamburger Associates
makes sure the business side of your practice gets the honest, personalized
attention it needs • For a whole new approach to office practice
CONTACT MARY ANN HAMBURGER
74 HUDSON AVENUE 201
MAPLEWOOD NEW JERSEY 07040
763-7394
Your Office is Your Largest Single Source
of Public Relations
Gain the Competitive Edge with
The leading Medical Space Planning and Interior Design firm.
• Expertise in creating a professional image resulting in
increased referrals from both patients and colleagues
• Comprehensive knowledge of the clinical and administrative
needs for each specialty
• Organized and reliable hands-on supervision from start to finish
• 100% Financing available
For Renovation, Relocation, or Expansion, call NOW for a
COMPLEMENTARY CONSULTATION
The most economically sound decision you will ever make
for the future of your practice.
AVATAR DESIGN, INC.
220 East 60th Street, New York, New York 10022
212-371-7337
VOL. 87— NUMBER 11 NOVEMBER 1990
945
ANESTHESIOLOGY
January
15 Meeting
6-9 P.M. — Ramada Inn, Clark
(New Jersey State Society
of Anesthesiologists)
17 Geriatric Anesthesia
8-9 A.M. — Dover General
Hospital, Dover
(AMNJ)
CARDIOLOGY
December
1 1 What’s New in Heart Failure
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
13 Newer Cardiac Drugs
8-9 P.M. — Centrastate Medical
Center, Freehold
(AMNJ)
DERMATOLOGY
January
8 Nail Disease
7-9 P.M. — Schering Corporation,
Kennilworth
(Dermatological Society of
New Jersey)
16 Case Presentations
6-9 P.M. — RCHP, US Route 1,
New Brunswick
(UMDNJ, Division of
Dermatology)
INFECTIOUS DISEASE
December
7- HIV and the Health
8 Professional
All day— UMDNJ-Newark
(UMDNJ)
January
9 Diagnosis and Treatment of
AIDS
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ and NJDOH)
9 Diagnosis and Treatment of
AIDS
11:30 A.M. -12:30 P.M. —Rahway
Hospital, Rahway
(AMNJ and NJDOH)
9 Diagnosis and Treatment of
AIDS
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ and NJDOH)
1 1 Identification and Management
of Asymptomatic HIV-Infection
10-11 A.M. — Marlboro Psychiatric
Hospital, Marlboro
(AMNJ and NJDOH)
23 Diagnosis and Treatment of
AIDS
12 Noon-1 P.M. — Union Hospital,
Union
(AMNJ and NJDOH)
30 Identification and Management
of Asymptomatic HIV-Infection
12 Noon-1 P.M. — Union Hospital,
Union
(AMNJ and NJDOH)
MEDICINE
December
I 39th Annual Clinical Meeting
8:30 A.M. -4:30 P.M. —Robert
Wood Johnson Medical School,
Piscataway
(American College of Surgeons
and AMNJ)
4 Grand Rounds
II 8:30-10 A.M. — Elizabeth General
18 Medical Center, Elizabeth
25 (Elizabeth General
Medical Center)
4 Nephrotoxicity of Common
Drugs
8- 9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
4 Case Presentation
9- 10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
5 Septic Shock
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
5 Clinical Abstract Meeting
1:30-5 P.M. — The Manor,
West Orange
( Oncology Society of New Jersey)
5 Legal Liability for T.D.
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
12- C02 Laser Surgery
13 7:30 A.M. -4:30 P.M. —UMDNJ,
Newark
(UMDNJ)
12 Critical Care Topics
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
12 Extrapyramidal Symptoms
2:30-3:30 P.M. —Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
12 Prevention of Lower Extremity
Amputations
1:30-2:30 P.M. — Roosevelt
Hospital, Metuchen
(AMNJ)
13- Sinus Endoscopy
14 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
13 Doctor/Patient Sex and
Medicolegal Issues
12 Noon-1 P.M. — Carrier
Foundation, Belle Mead
( Carrier Foundation)
13 New Developments in
Emergency Medical Care in
New Jersey
12 Noon-1 P.M. — Community
Medical Center, Toms River
(AMNJ)
18 Evaluation of Cholesterol
Awareness
9-10 A.M. — Holy Name Hospital,
Teaneck
(Holy Name Hospital)
19 Aspiration Syndrome in the
Mentally Retarded
9-10 A.M. — Warren Hospital,
Phillipsburg
(AMNJ)
19 Strokes
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
2 1 Prevention of Lower Extremity
Amputations
12 Noon-1 P.M. — South Jersey
946
NEW JERSEY MEDICINE _
1~STlff Hahnemann
lJZ\UJ University
Department of Medicine
Department of Medicine
GRAND ROUNDS
WEDNESDAYS
8:30 a. m. -9:30 a.m.
November-December, 1990
NOVEMBER, 1990
November 7, 1990
STEROID ABUSE IN THE ATHLETE
Robert Cantu, MD
Chairman of Surgery
Director, Services of Sports Medicine
Emerson Hospital, Concord, MA
Consultant, Sports Medicine Committee
USA American Boxing Federation
November 14, 1990
CONTROVERSIES IN NON-CARDIAC CHEST
PAIN (Gastro-Esophageal Reflux, Achalasia)
Sidney Cohen, MD
Professor and Chairman of Medicine
Temple University School of Medicine
Philadelphia, PA
November 21, 1990
AGING OF THE SKIN
Richard L. Speilvogel, MD
Professor of Medicine and Dermatology
Director, Division of Dermatology
Hahnemann University
November 28, 1990
MEDICAL MANAGEMENT OF DEPRESSION
AND ANXIETY
Gary Tollefson, MD, PhD
Associate Professor of Psychiatry
University of Minnesota, MN
Jonathan O. Cole, MD
Chief, Psychopharmacology Program
McLean Hospital, Belmont, MA
DECEMBER, 1990
December 5, 1990
PTCA VS BYPASS GRAFT SURGERY FOR CORONARY
ARTERY DISEASE
William S. Frankl, MD
Vischer Professor of Medicine and Chairman,
Department of Medicine
Director, Likoff Cardiovascular Institute
Hahnemann University
December 12, 1990
ABNORMALITIES OF THROMBOSIS AND
THROMBOEMBOLISM
Daniel Deykin, MD
Chief of Medicine, Director, Health Services
Research and Development
Boston VA Medical Center, MA
December 19, 1990
DIVISION OF PULMONARY MEDICINE AND
CRITICAL CARE
Edward Schulman, MD
Associate Professor of Medicine
Director, Division of Pulmonary and Critical
Care Medicine
Hahnemann Universtiy
WEDNESDAY MEDICAL SEMINAR SERIES
8:30 a.m. -3:30 p.m.
November 7, 1990
MEDICINE IN ATHLETICS
November 28, 1990
MEDICAL MANAGEMENT OF
DEPRESSION AND ANXIETY
December 12, 1990
ABNORMALITIES OF THROMBOSIS
AND THROMBOEMBOLISM
Seminar Directors:
William S. Frankl, MD
Professor of Medicine
and Chairman
Department of Medicine
Allan B. Schwartz, MD
Professor of Medicine
Director, Continuing
Medical Education for the
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd FI. New College Bldg.
Hahnemann University
15th Street Entrance
15th & Vine Streets
Philadelphia. PA
As an organization accredited by the Accreditation Council for Continuing Medical
Education (ACCME), Hahnemann University designates this continuing medical
education activity as Category 1 of the Physician’s Recognition Award of the
American Medical Association. One credit hour may be claimed for each hour
of participation by the individual physician.
For Information, call the Office of Continuing Education at (215) 448-8263
vm B7— NIIMRFR 11 NOVEMBER 1990
947
Hospital System, Bridgeton
(AMNJ and NJDOH)
26 Diabetic Retinopathy
12 Noon-1 P.M. — Union Hospital,
Union
(AMNJ and NJDOH)
January
2 Hyperalimentation
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
8 Internal Medicine Update and
15 Board Review
22 5:30-7:30 P.M. — Cooper Hospital/
29 University Medical Center,
Camden
( Cooper Hospital/University
Medical Center)
9 Diabetic Retinopathy
1:30-2:30 P.M. — Roosevelt
Hospital, Metuchen
(AMNJ)
9 Diabetic Nephropathy
2-3 P.M. — Welkind Rehabilitation
Hospital, Chester
(AMNJ)
9 Living Wills
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
9 Hypertension— New Drug
Regimens
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
10- Sinus Endoscopy
11 7:30 A M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
14 Diabetic Nephropathy
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
15 Beyond Correction of Anemia —
Erythropoietin in the ESRD
Patient
6:30-9:30 P.M. — Overlook
Hospital, Summit
(Nephrology Society of
New Jersey)
15 Asbestos-Associated Diseases
8-9 A. M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
16 Diabetic Nephropathy
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
16 Internal Medicine Review
23 Course
30 4-7 P.M. — University Hospital,
New Brunswick
(AMNJ andkUMDNJ)
17 New Treatment Modalities and
Implications for the Future in
Diabetes
10-11 A.M. — Hunterdon
Developmental Center,
Cedar Grove
(AMNJ)
18 Juvenile Onset Diabetes
8-9 A.M. — Dover General
Hospital, Dover
(AMNJ)
23 Peptic Ulcer Disease
2:30-3:30 P.M. —Trenton
Psychiatric Hospital, Trenton
(AMNJ)
25 Detoxification: Commonly Used
Drugs
10-11 A.M. — Marlboro Psychiatric
Hospital. Marlboro
(AMNJ)
30 Chronic Epstein-Barr Virus
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
OBSTETRICS/GYNECOLOGY
December
6 Diabetes in Pregnancy
8-9 A.M. — Our Lady of Lourdes
Medical Center, Camden
(AMNJ)
13- C02 Laser Applications
15 in Ob/Gyn
8 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
January
9 Estrogen Replacement Therapy
10:30-11:30 A. M.— St. Mary’s
Hospital, Passaic
(AMNJ)
11 Postoperative Toxic Shock
Syndrome
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
14 Adolescent Menstrual Disorders
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ)
18- 4th Annual Practice Approaches
21 to Ob/Gyn
7:30A.M.-1 P.M. — Cozamel,
Mexico
(UMDNJ)
25 Diabetes in Pregnancy
7:30-8:30 A.M. —Kennedy
Memorial Hospital,
Washington Township
(AMNJ)
ONCOLOGY
December
5 Annual Clinical Abstract
Meeting
1:30-5 P.M. — The Manor,
West Orange
( Oncology Society of New Jersey)
13 Meeting: Head and Neck
Oncology' Section
6:30-9:30 P.M.—’ The Hyatt,
New Brunswick
(AMNJ)
14 Tumor Board Conference
11 A.M. -12 Noon — Wallkill Valley
Hospital, Sussex
(Wallkill Valley Hospital and
AMNJ)
27 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center,
Vineland
(AMNJ)
January
16 Current Chemotherapy
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
SURGERY AND ITS SPECIALTIES
December
10 Surgical Treatment of Peptic
Ulcer Disease
11:30 A.M. -1 P.M. —East Orange
General Hospital, East Orange
(AMNJ)
15- C02 Laser — ENT
16 8 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
January
7 Surgical Treatment of Chronic
Pancreatis
11:30 A.M.-l P.M. —East Orange
General Hospital,
East Orange
(AMNJ)
10- Sinus Endoscopy
11 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
1 1 Postoperative Toxic Shock
Syndrome
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
UROLOGY
December
6 Grand Rounds
13 7-9 P.M. — Robert Wood Johnson
20 Medical School, Piscataway
(UMDNJ)
January
8 Winter Meeting
Holiday Inn, Jamesburg
(Urology Society of New Jersey)
948
NEW JERSEY MEDICINE
\
PHILADELPHIA HEART INSTITUTE
Presbyterian Medical Center
I Cardiology
Update v
designed for the physician and provides an intensive
survey of the current status of clinical cardiology . . .
Wednesday, December 5, 1990
Angina Pectoris
Moderator: Ami E. Iskandrian, M.D.
3:00-3:30 Angina pectoris in patients with
coronary heart disease
3:30-4:00 Angina pectoris in patients with
non-coronary disease
4:00-5:00 Case Presentations
Panel Discussion
Philip A. Bhark, M.D.
Michael S. Feldman, M.D.
Marvin Rosner, D.O.
■ Case Presentations and Panel Discussions I
■ CME Credits *
■ bio Registration Fee
■ Call for Reservation 215-662-8627
Scheie Auditorium
Presbyterian Medical Center
39th &. Market Streets
Philadelphia, Pennsylvania 19104
Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
* Presbyterian Medical Center designates this continued medical education activity for 2 credit hours in Cat-
egory I of the Physicians' Recognition Award of the American Medical Association and the Pennsylvania Medical j
Society Membership requirement, nine sessions, 19 credits.
J
Ami E. Iskandrian, M.D.
William Corin, M.D.
Sally G. Beer, M.D.
William J. Untereker, M.D.
Jan R. Weber, M.D.
VOL. 87— NUMBER 11 NOVEMBER 1990
951
ce
N
IN MEMORIAM
Frederick S. Barnes. Internist
Frederick Sheldon Barnes, MD,
died on April 4, 1990. Born in 1922,
Dr. Barnes received his medical
degree from the State University of
New York College of Medicine,
New York, in 1946. Dr. Barnes had
his practice in Passaic. Dr. Barnes
was a member of the American
Medical Association and of our
Hudson County component, and
was a fellow of the American Col-
lege of Legal Medicine.
Alfred Del Vecchio. After a
long illness, Forked River resident
Alfred Del Vecchio, MD, died on
June 26, 1990, at the age of 64.
Born in Hoboken on September 13,
1925, Dr. Del Vecchio earned his
medical degree from the University
of Bologna, Italy, in 1956. Dr. Del
Vecchio received his New Jersey
medical license in 1957 and served
his internship and residency at the
former Martland Memorial Cen-
ter, Newark. Dr. Del Vecchio was
affiliated with: Pascack Valley
Hospital, Westwood; Holy Name
Hospital, Teaneck; Hackensack
Medical Center; and Community
Medical Center, Toms River,
where he helped to establish the
electroencephalography depart-
ment. Retired since 1986, Dr. Del
Vecchio maintained a family prac-
tice in Hillsdale and Toms River.
Dr. Del Vecchio was a lieutenant in
the United States Air Force from
1943 to 1947. Dr. Del Vecchio was
a member of the American Medi-
cal Association and of our Bergen
County component.
Frederick J. Faux. Retired
Woodbury resident Frederick John
Faux, MD, died at the age of 79 on
February 3, 1990. Born in Philadel-
phia on February 10, 1910, Dr.
Faux earned his medical degree
from Jefferson Medical College of
Philadelphia in 1939 and his New
Jersey medical license the follow-
ing year. Dr. Faux served his resi-
dency and internship at Cooper
Hospital, Camden. Board certified
in obstetrics-gynecology, Dr. Faux
practiced in Woodbury. He was af-
filiated with Underwood Hospital,
Woodbury, and Cooper Medical
Center, Camden. Dr. Faux
served in the U.S. Navy as a
lieutenant commander from 1942
to 1946. Dr. Faux was a member of
our Gloucester County component,
of the American Medical Associa-
tion, of the New Jersey Obstetrics-
Gynecology Society, and of the
Philadelphia Obstetrics Society,
and a fellow of the American Col-
lege of Obstetricians and Gyne-
cologists. Dr. Faux served on the
Council of the New Jersey Ob-
stetrics-Gynecology Society and
was past-president of our Glou-
cester County component.
Urban R. Finnerty. At the age
of 80, Urban Raymond Finnerty,
MD, of Myrtle Beach, South Caro-
lina, died on July 12, 1990. Born
August 19, 1909, in Montclair, Dr.
Finnerty earned his medical degree
from Georgetown University
School of Medicine, Washington,
DC, in 1934. He received his New
Jersey medical license one year
later. A colon and rectal surgeon,
Dr. Finnerty maintained a practice
in Montclair. He was affiliated
with the former St. Vincent’s Hos-
pital, Montclair; St. Mary’s Hospi-
tal, Orange; St. Mary’s Hospital,
Passaic; The Mountainside Hospi-
B
11
Si
tf
tal, Montclair; Lutheran Medical
Center, New York; and the former
Hospital of St. Barnabas for |g
Women and Children, Newark. Dr.
Finnerty was a member of our
Essex County component, of the
American Medical Association,
and of the Medical Society of :
South Carolina, and a fellow of the j i
International College of Surgeons. i
Dr. Finnerty served as a com- If
mander in the U.S. National Re-
serves from 1942 to 1946.
Harold H. Goldberg. Board
certified in psychiatry and neu-
rology, Harold H. Goldberg, MD,
died on July 16, 1990, at the age of
67. Born in Chicago, on July 28,
1922, Dr. Goldberg earned his
medical degree from Albany Medi-
cal College, New York, in 1952, his
New York medical license in 1953,
and his New Jersey medical license
in 1960. Dr. Goldberg interned at
Kings County Hospital Center,
Brooklyn. Dr. Goldberg main-
tained a practice in Brooklyn and
Hackensack, and was affiliated
with Kings County Hospital Cen-
ter; Brooklyn Hospital; Methodist
Hospital, Brooklyn; Pascack Val-
ley Hospital, Westwood; Hacken-
sack Medical Center; Bergen Pines
County Hospital, Paramus; and
Holy Name Hospital, Teaneck. Dr.
Goldberg served in the U.S. Navy
during World War II. Dr. Goldberg
was a member of the American
Medical Association and of our
Bergen County component, and
was a fellow of the American
Academy of Neurology.
Jamie Martinez. Word has
been received of the death of Jamie
Martinez, MD, on July 17, 1990, at
952
NEW JERSEY MEDICINE
the age of 66. Born in Bogota, Co-
lombia, in 1924, Dr. Martinez re-
ceived his medical degree from the
National University of Colombia,
Bogota, Colombia, in 1952. Dr.
Martinez emigrated to the United
States in 1949. He served an in-
ternship and residency at General
Hospital Center at Passaic, and a
residency in surgery at Mount
Sinai Medical Center, New York.
An emergency room general sur-
geon specializing in abdominal
surgery, Dr. Martinez was af-
filiated with General Hospital
Center at Passaic; Beth Israel Hos-
pital, Passaic; and Pascack Valley
Hospital, Westwood. Dr. Martinez
maintained a private practice in
Passaic and Fair Lawn. He was
employed by the Riverfront State
Prison, Camden, as an assistant
medical director. Dr. Martinez
served in the United States Army
Medical Corps during the Korean
War, stationed at Gorgas Hospital,
Panama. Dr. Martinez was a mem-
ber of our Passaic County compo-
nent and a fellow of the Associa-
tion of Military Surgeons U.S., and
of the American Society of Ab-
dominal Surgeons.
Jacob A. Riese. A physician of
geriatrics and a resident of
Teaneck, Jacob Atkin Riese, MD,
died on May 14, 1990, at the age
of 85. Born in New York City on
August 6, 1904, Dr. Riese attended
the University of Pennsylvania
School of Medicine, Philadelphia,
earning his medical degree in 1928.
In 1930, Dr. Riese received his New
Jersey medical license. Retired for
almost ten years, Dr. Riese main-
tained a practice in New York City
and Jersey City, and was affiliated
with several hospitals: Jersey City
Medical Center; the former North
Hudson Hospital, Weehawken; St.
Francis Hospital, Jersey City; St.
Mary Hospital, Hoboken; Holy
Name Hospital, Teaneck; B.S.
Pollack Hospital, Jersey City;
Christ Hospital, Jersey City; and
Jewish Hospital and Rehabili-
tation Center, Jersey City. Dr.
Riese was a member of our Hudson
County component and of the
American Medical Association,
and a fellow of the International
Academy of Proctology and of the
American College of Gastro-
enterology.
Edwin R. Rosner. After a
lengthy illness, Edwin R. Rosner,
MD, died on August 3, 1990, at the
age of 81. Born in Vienna, Austria,
on October 3, 1908, Dr. Rosner
earned his medical degree from the
University of Vienna, Austria, in
1934, and practiced obstetrics and
gynecology in Austria for several
years before immigrating to the
United States in 1939 and earning
his New Jersey medical license in
1943. Dr. Rosner interned at West
Jersey Hospital, Camden. Special-
izing in medical hypnosis, Dr.
Rosner had a practice in Haddon-
field and Collingswood and was af-
filiated with West Jersey Hospital,
Camden. Dr. Rosner was a mem-
ber of our Camden County compo-
nent and of the American Medical
Association, and a fellow of the
American Academy of Family
Practice. He served on the advisory
committee of general practice of
the Medical Society of New Jersey,
and as president of the New Jersey
Academy of General Practice in
1953. Dr. Rosner was an Army cap-
tain with the 391st Battalion from
1944 to 1945.
Nelson W. Sisson. On August 7,
1990, Nelson White Sisson, MD,
died at the age of 90. Born on De-
cember 31, 1899, in Peaksville, Vir-
ginia, Dr. Sisson received his medi-
cal degree from the University of
Virginia School of Medicine, in
1924. Dr. Sisson earned his New
Jersey medical license in 1933. He
served an internship at The Hospi-
tal Center at Orange and a resi-
dency at St. Luke’s Hospital and
at Bellevue Hospital, both in New
York. Dr. Sisson was a school phy-
sician at Mohonk School of Boys,
Lake Mohonk, New York, for one
year. Dr. Sisson had a practice in
East Orange and was affiliated
with Bellevue Hospital, The Hos-
pital Center at Orange, and Vet-
erans Administration Medical
Center, Lyons. From 1933 to 1957,
Dr. Sisson was a professor of
otolaryngology at New York Uni-
versity School of Medicine. After
retiring to Virginia from his private
practice in 1966, Dr. Sisson served
on the medical staff at E.I. Du-
Pont, Waynesboro, Virginia, until
1970. Dr. Sisson was a member of
the American Medical Association,
and of our Essex County compo-
nent, and a diplomate of the Board
of Otolaryngology, and a fellow of
the American College of Surgeons.
Dr. Sisson’s gift trust funds the
Nelson W. Sisson Eminent Schol-
ars Professorship in Otolaryn-
gology and the Nelson W. Sisson
Medical Scholarship Endowment
Fund at the University of Virginia
School of Medicine. Dr. Sisson
served in the United States Infan-
try during World War I.
David H. Welsh. Panther Val-
ley community resident, David
Harrison Welsh, MD, died August
18, 1990, at the age of 66. Born in
Morristown on April 5, 1924, Dr.
Welsh received his medical degree
from Temple University School of
Medicine, Philadelphia, in 1949
and his New Jersey medical license
in 1952. Dr. Welsh served his resi-
dency at Allegheny General Hospi-
tal, Pittsburgh, Pennsylvania. An
anesthesiologist at Newton Me-
morial Hospital, Dr. Welsh served
as chief of anesthesiology and as
president of the medical staff and
as a member of the Board of Gov-
ernors. In addition, Dr. Welsh was
a member of the Newton Board of
Health. Dr. Welsh was a member
of our Sussex County component
and of the American Medical As-
sociation, and a past-president of
the Sussex County Heart Associa-
tion, and a fellow of the American
College of Anesthesiologists. Dr.
Welsh served in the United States
Navy from 1944 to 1945. Dr. Welsh
retired in 1985.
_VQ_L 87— NUMBER 11 NOVEMBER 1990
953
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NEW JERSEY MEDICINE
NO-FAULT PIP SCHEDULE
On November 26, 1990, acting under the imminent peril
provisions of the Administrative Procedure Act, the
Administration adopted a PIP medical fee schedule (automobile
no-fault) to be effective January 1, 1991. MSNJ attorneys
will request the courts to grant an injunction against the
no-fault automobile fee schedule in early December. The
Society has mailed copies of the schedule to hospital medical
staffs, county societies, and specialty societies for review.
Meanwhile, litigation against the no-fault law continues.
The Tax Court has bifurcated the issues. Trial on the
$100-a-year physician licensing tax has been completed and a
decision is expected shortly.
MEDICARE MANDATORY ASSIGNMENT
Assemblyman James E. McGreevey (D-Middlesex) has announced
he will move all out to pursue mandatory Medicare assignment.
All physicians opposed to that legislation should call and
write their assemblymen to express such opposition. Mr.
McGreevey may be contacted at his legislative office located
at 1000 Route 9, Woodbridge, NJ 07095.
WHEN YOUR HMO RUNS OUT OF MONEY
There is no question that the country is heading into hard
times: the real estate market has dried up; the savings and
loan industry is foundering despite government bailout
attempts; and prices on everything from milk to heating oil
are sky high and climbing. No doubt some of our readers
already are feeling this economic pinch.
HMOs , the brainchild of the 1970s, that promised members the
benefits of the best health care system in the world on a
prepaid basis, also are feeling the pinch. Although some
HMOs are efficiently run and economically sound, others are
scrambling to survive. In the last two years, we have seen:
the bankruptcy of Maxicare, a major California-based national
HMO; the liquidation of Foundation Health Plan, a New Jersey
subsidiary of another California HMO; the sale by John
Hancock Mutual Life Insurance of all its HMO plans nation-
wide; and the insolvency of Omnicare/The HMO, Inc. (1)
Needless to say, these events may make physicians who are
contracted with HMOs feel somewhat insecure. Are you
obligated to continue providing services to HMO subscribers
after it is clear that the HMO no longer can pay for those
services? If you have rendered services prior to the
insolvency that have not yet been paid, will you get paid,
and if so, how?
The simple answer is, there is no simple answer. Various HMO
provider contracts contain different provisions (or no
provisions at all) to deal with these "unlikely"
eventualities. This writer always has insisted that
insolvency insurance be carried by the HMO, and that a
requirement to provide proof of such insurance be contained
in our clients' contracts. HMOs, of course, would rather not
incur the expense of such insurance, and oppose this
requirement vigorously.
The bankruptcy courts may consider HMO provider contracts
executory, i.e. contracts that may be specifically assumed
or rejected by the bankruptcy trustee. In the latter case,
the contract is terminated. In the event the trustee assumes
the executory contract, the contractor-physician would be
bound to continue providing services, but would have a
superpriority claim to assets of the bankrupt estate for
services rendered after the assumption.
Of primary importance, however, is an understanding that your
professional relationship with the patient is not necessarily
dependent upon the contract with the HMO or payment
thereunder. You still may be obligated to continue treating
the HMO patients, and may not simply abandon them because
their payment source has dried up. The old, tried and true
requirements of reasonable notice and sufficient opportunity
to find alternative care still apply before you may terminate
a patient relationship. What is reasonable and sufficient?
That determination will vary from case to case, depending
upon the patient's condition, the availability of other
physicians, and other factors.
For these reasons, it is important to anticipate the possible
economic failure of the HMO at the time you enter into or
renew your provider agreement. Insolvency insurance may
assure that you will continue to be paid in the event of an
insolvency, and should always be a nonnegotiable term of an
HMO provider contract. Other precautions may be taken as
well; but remember that, if your HMO becomes insolvent, your
professional responsibilities to the patients are not
necessarily altered by that event. William P. Isele
1. A public notice was published in the October 18, 1990,
issue of New Jersey Law Journal, informing subscribers and
creditors of Omnicare/The HMO, Inc. that liquidation of the
HMO had been ordered by the Superior Court of New Jersey, and
approved by the U.S. Bankruptcy Court. All persons with
claims against Omnicare for services rendered prior to
September 25, 1990, must file a proof of claim form and
signed affidavit, together with supporting documentation, no
later than January 31, 1991, or they will be forever barred
from asserting such claims.
December 1990
MSNJ
NEWSLETTER
PROFESSIONAL Two papers were submitted to NEW JERSEY MEDICINE, almost si-
CONDUCT multaneously, on similar topics. The topics — professional conduct and
professional regulations — are timely and important. The emphases vary.
We, therefore, publish both articles for your edification: “Professional
Review and Regulations,” page 983 and “Professional Medical Conduct
Reform Act,” page 989.
GROWING HEALTH CARE Governor James Florio joined with six governors to warn that state
CRISIS governments must develop comprehensive plans to meet the health care
crisis. Governor Florio, in a National Governors Association press con-
ference, said that states should not wait for federal help in devising
solutions to health care problems. “The federal government doesn’t
appear to be headed that way, so the states really have no choice but
to come up with their own strategies,” Governor Florio said.
HERNIA Negotiations with Pennsylvania Blue Shield in connection with assis-
PROCEDURES tants at hernia procedures still are incomplete and are on hold. Targeted
are assistant fees. It is the intent of HCFA to deny payment to those
procedures where, nationally, assistants were used in less than 5 percent
of cases. If herniorrhaphy falls into this group, further negotiations with
Pennsylvania Blue Shield would be redundant. Please note an excerpt
from a letter from Joseph Ricci: “Nevertheless, with regard to the hernia
codes, and as you are well aware, all strangulated and incarcerated
hernias are eligible for reimbursement. The codes specifically addressing
strangulated and/or incarcerated hernias address only inguinal hernias.
Therefore, for any strangulated and/or incarcerated hernias not inguinal
in origin, surgeons in New Jersey may report the not otherwise classified
code (NOC) which is 49999. You had requested the establishment of a
precertification process for those hernias associated with unusual medi-
cal circumstances. Preauthorization processes are not usually part of the
PRESIDENT’S MESSAGE
Douglas M. Costabile, MD
The time has come for physicians to join forces. We need to protect our turf, not to be divided
and conquered.
Physicians need to be politically minded. And now is the time to act — to give input to our
legislators.
Next year Assembly and Senate members will be running for election. JEMPAC and MEDAC
will need your contributions. JEMPAC will accept a personal check and MEDAC will accept
a corporate check. Remember: money talks and we need representatives in government that
will listen to and evaluate our concerns. Write that $100 check now. Your future is at stake.
The Medical Society of New Jersey and the AMA have been working on your behalf at the state
and national levels— and we want to continue the work.
VOL. 87— NUMBER 12 DECEMBER 1990
965
MSNJ NEWSLETTER
Medicare Part B Program. Given the fact that provisions cannot be made
for such a program for those hernias associated with unusual medical
circumstances, the appropriate code should be reported along with modi-
fier 22. The addition of modifier 22 will cause a suspension and review
of the submitted surgical claim. If unusual circumstances prevail, reim-
bursement will follow.” This may be interpreted as follows: For any t
complicated hernia, other than inguinal hernia, an NOC code should be
used. This automatically will allow for an assistant’s fee. In cases where,
in the surgeon’s best clinical judgment, a hernia repair is otherwise
complicated and requires a surgical assistant, provisions for payment to
the assistant is allowed. In order to insure payment for the assistant’s
fee, the operative record should document clearly the need for an assis-
tant, and the appropriate code should be reported with a modifier. It
is my impression that cases falling into this category would be large or
direct hernias where a mesh repair is used. □ Ian D. Samson, MD
MEDICARE HOTLINE A new Medicare hotline has been introduced in New Jersey to answer
senior citizens’ questions about new Medicare reimbursement and filing
rules. The toll-free number is 800/648-6847, and is open from 9:30 AM
to 12 noon, five days a week.
MANDATORY MEDICARE The following letter was sent to Governor Florio from Bessie M. Sullivan,
ASSIGNMENT MD, president of the Union County Medical Society:
I am writing in response to the article that was in this morning’s The
Star-Ledger regarding the report of your Health Care Commission and
the remarks attributed to you, namely, “Senior citizens are facing the
problem of runaway health costs because there are no controls on how
much above Medicare rates doctors can charge.” This statement is
patently untrue.
If your Commission studied the issue for six months, they must be
conversant with the MAAC, the Maximum Allowable Actual Charge
that nonparticipating physicians are by federal law not allowed to charge
above for Medicare patients. Each physician has an individual MAAC
that is based on charges accumulated from the previous year, except in
1986 when they were introduced and MAACs were based on the period
April- June 1984. If a procedure was not done the previous year, the
physician is bound by Medicare’s determination. New physicians in
practice when the MAAC first came out in 1986 were allowed to charge
only 50 percent of the prevailing rate. MAACs have not been allowed
to go up more than U/2 percent each year and usually less. Additionally,
most physicians (over 70 percent nationwide) voluntarily froze their
Medicare fees in 1983 at the request of the AMA, so when the MAACs
came in, they were based on these already frozen fees.
If your Commission was entrusted with reviewing health care in New
Jersey, we would assume that they had access to and reviewed HCFA
regulations regarding physicians’ fees. We are, therefore, at a loss to
understand how they reached the conclusion that physicians’ fees for
Medicare patients are not capped when in fact physicians’ fees are
closely monitored by the federal government. We are concerned that this
misinformation is being distributed to newspapers, which is neither in
the best interest of senior citizens nor the physicians treating these
patients.
We would be remiss if we did not mention that there is a statewide Senior
Citizen Medical Courtesy program wherein physicians voluntarily accept
966
NEW JERSEY MEDICINE
MSNJ NEWSLETTER
assignment on seniors, and that over 70 percent of Medicare claims in
New Jersey are submitted on an assigned basis, nonparticipating phy-
sicians accepting Medicare’s allowance as payment in full, rather than
billing according to their MAACs.
AMA CALLS FOR
KUSSEROW DISMISSAL
The American Medical Association has called upon President George
Bush to seek the resignation of Richard Kusserow, the Inspector General
of the Department of Health and Human Services, because of lack of
trust and confidence among U.S. physicians. The AMA acted after a
program televised on ABC-TV’s “Prime Time,” that showed Mr.
Kusserow to be reckless and wholly lacking in candor and impartiality.
“Mr. Kusserow has for nine years presided over the process in which
the Department of Health and Human Services investigates, judges, and
sanctions physicians in the Medicare program who are accused of
substandard care or fraudulent billing practices.”
Dr. James S. Todd’s comments mirrored those of a letter sent to Presi-
dent George Bush by Joseph T. Painter, MD, chairman of the AMA
Board of Trustees. “In that role he has been zealous in his determination
to find and punish physicians who are substandard and who abuse the
program. We want them out of the program — and the profession — every
bit as much as the government wants them out,” Dr. Todd said.
“While carrying out his duties, Mr. Kusserow is widely perceived to have
ignored, indeed fought against, principles of fairness which are routine
in the American administrative and judicial system. As a result, many
competent and honest physicians have been severely and improperly
damaged and many more have been unnecessarily harassed.”
DISPOSAL OF
RADIOACTIVE WASTE
The disposal of low-level radioactive wastes may seem like a minor
concern among medicine’s worries. But consider these facts: Twenty-five
to 30 percent of all low-level radioactive wastes produced in the United
States result directly from medical uses. About 120 million nuclear
medicine procedures contribute annually to low-level radioactive waste
production. Research is a significant contributor to low-level radioactive
waste production. For example, radioisotopes are used in the develop-
ment and evaluation of about 90 percent of all new drugs. Universities,
medical schools, hospitals, laboratories, and medical practices are
among the producers of low-level radioactive wastes. Their activities
clearly benefit individual patients and society as a whole.
Then why is disposal of radioactive wastes a problem? In response,
Congress passed the Low-Level Radioactive Wastes Policy Act in 1980.
Under this bill, each state would eventually become responsible for
disposal of radioactive wastes generated within its boundaries. The act
recommended that states participate in regional groupings or compacts
to improve the cost effectiveness of disposal facilities. It also stated that
any regional facility could exclude wastes from outside its region after
January 1, 1986.
Physicians can play a key role in helping their states develop acceptable
disposal facilities for low-level radioactive wastes. Their medical training
can provide an informed perspective on the personal and public health
risks related to waste disposal. But more importantly, they can describe
the beneficial uses of procedures that produce radioactive wastes and
how these uses will be compromised if disposal sites for the wastes are
unavailable.
Consider becoming involved in efforts to establish disposal facilities.
First, contact representatives of your state’s radiation control program
VOL. 87— NUMBER 12 DECEMBER 1990
967
MSNJ NEWSLETTER
or health agency. Arrange to meet with them, determine whether your
I
state is involved in a compact, and offer your support. Encourage these
representatives to consider what will be done if a disposal site is not
available by January 1, 1993. Stress the need to develop one or more
storage sites for low-level wastes as an intermediate measure until a
disposal site becomes available.
Secondly, encourage your medical society’s public health or environmen-
tal health committee to become involved. Pass policy regarding the
disposal of low-level radioactive wastes and then promote it. Through
lobbying efforts or by working with public health authorities, the medical
society can influence disposal facility plans.
Finally, physicians can help persuade their patients, the media, and
community groups that radioactive materials can be beneficial. Seek
opportunities to lead discussions in classrooms or speak to public
audiences.
CALL FOR PAPERS:
SPECIAL ISSUE
ON COMPUTERS
NEW JERSEY MEDICINE invites interested persons to submit articles
or suggestions for a special issue on Computers in Medicine to be pub-
lished in spring 1991. Under the guest editorship of Richard M. Ball,
MD, this special issue will cover a variety of topics directed toward
computer use by the physician. Specific topics for articles might include:
medical infomatics; getting physicians to use computers; experiences
using on-line medical databases; drug interaction programs; coding soft-
ware; radiologic imaging; computer-assisted learning and testing; com-
puter-stored medical records; doctors as programmers; and personal
experiences with office business computer systems. Please send your
inquiries or manuscripts to Richard M. Ball, MD, 1907 Park Avenue,
South Plainfield, NJ 07080.
PHYSICIAN
OFFICE
LABORATORY
Kathleen Voldish, CLA (ASCP), is available to present a program to
physicians entitled “How To Prepare Your Physician Office Laboratory
for CLIA-88 Regulations.” The one-hour program can be presented by
calling 609/428-8414.
The controversy over the upcoming Clinical Laboratory Improvement
Act Amendments (CLIA-88) continues. CLIA-88 will federally regulate
all physician office laboratories. Numerous comments were received by
the Health Care Financing Administration (HCFA) concerning the ex-
pansion of Level I tests, relaxing the physician director requirements in
Level II, and linking the personnel requirements to test complexity in
Level II.
Presentations are being made concerning equivalent routes for both
office laboratory personnel and physicians to meet the requirements
found in Level II. A competency examination plus experience is hoped
to be a possible solution.
The New Jersey State Department of Health has been working on regu-
lations similar to CLIA-88 to regulate office laboratories. If the state’s
requirements are equal to or greater than those of CLIA, the state would
be given jurisdiction over regulating POLs. The state regulations could
possibly be implemented before CLIA-88 regulations are finalized.
Physicians must start preparing office laboratories now to be prepared
for upcoming regulations.
FINI “Don’t get too big for your britches — you’re sure to be exposed in the
end.”
NEW JERSEY MEDICINE
968
IB
LIABILITY IN COSTLY
AIDS CASES EXPANDS
RAPIDLY AS
ATTORNEYS TARGET
PHYSICIANS AND
HOSPITALS
PlOFiSSIOH^L
LIABILITY
Brace for a barrage of new AIDS liability cases, warns an attorney who
has become a specialist in this area. Duncan Barr, of San Francisco, said
that although the first AIDS malpractice cases to reach the courts were
directed against blood banks, trial lawyers now routinely include phy-
sicians, hospitals, and medical groups in their complaints. The tendency
of the blood banks to settle such cases early “often leaves the doctors
and hospitals out there by themselves,” said Barr, who is with the firm
of O’Connor, Cohn, Dillon and Barr.
Look at just two AIDS cases in which juries levied huge awards against
physicians and hospitals and the prospects of what lies ahead become
clear. Last June, an Arizona jury awarded $28.7 million to five-year-old
Alex Edwards who contracted AIDS from a blood transfusion given
shortly after his birth. On the hook for the huge amount were
neonatologist Abraham Kuruvilla, MD, and the clinic with which he is
associated, Neonatology Associates of Phoenix. Dr. Robert Crawford,
president of Mutual Insurance Company of Arizona (MICA), the com-
pany insuring Dr. Kuruvilla, said: “A verdict of $28.7 million was
rendered against the doctor and the group because of the doctor’s actions
in trying to save the life of Alex Edwards when he was two days old.
MICA stated then, as we do now, that the doctor met the standard of
care. The jury obviously did not agree. We feel their decision was an
emotional one stemming from confusion, anger, and fear of the AIDS
disease rather than the facts of the medical treatment.” MICA success-
fully negotiated an out-of-court agreement with the Edwards family last
month “to resolve the litigation in the best interests of both the family
and the doctor,” Dr. Crawford said. The agreement is for payment of
approximately $6 million with a structured plan to provide lifetime
medical care to the Edwards boy. The settlement has been approved
by the court, Dr. Crawford said. In the Edwards case, Blood Systems,
Inc., a parent of United Blood Service of Arizona and Samaritan Health
Services also were named as defendants. Both settled and were dismissed
from the case in February, leaving Dr. Kuruvilla as the remaining defen-
dant. Although the Edwards case has been resolved, a second almost
identical case involving a baby girl born on the same day as Alex at
the same hospital who also received blood containing the HIV virus also
is pending in Arizona. Blood Services Inc. of Scottsdale and Samaritan
Health Services Inc. of Phoenix were named as defendants along with
Dr. Kuruvilla and Neonatology Associates and two other laboratories,
but the physicians, his medical group, and the laboratories quickly were
dismissed with apologies from the trial lawyer for improperly naming
them.
In a second case, a Columbus, Ohio woman who contracted the AIDS
virus from a blood transfusion given after breast reduction surgery won
a $12 million verdict against Dr. John T. Cozzone and Mount Carmel
Medical Center last March. Holly Sutro Lalonde, 25, also named the
American Red Cross and its central Ohio chapter, Ohio Plastic Surgeons,
and another physician, Dr. Gerald A. Drabyn. However, the plaintiffs,
70L. 87— NUMBER 12 DECEMBER 1990
971
PROFESSIONAL LIABILITY
Lalonde and her mother, dismissed Ohio Plastic Surgeons and Dr.
Drabyn. The Red Cross settled out of court for an undisclosed amount.
The Columbus woman’s case centered upon her arguments that the
transfusion was unwarranted and ordered without permission from her
physician, Dr. Drabyn, who assisted at the surgery, and that the hospital
was negligent in screening and selling its products. As has often been
the case in the first wave of transfusion suits, Lalonde was a patient
who received AIDS-tainted blood just before full blood screening
procedures were in place. According to Columbus Dispatch, the Red j
Cross received testing kits for the virus March 7, 1985, and had begun
phase-in testing by March 18, one week before Lalonde’s surgery.
The Edwards and Lalonde cases may be chilling indicators of what the
health care community will be up against in the near future. Just look
at the number of potential cases. An estimated 26 million people received
transfusions between 1977 and 1985, the years when the AIDS epidemic
was building fast. It was not until 1985 that tests to screen blood for
the virus were approved and used.
“If nothing else, AIDS has brought a greater awareness of the risk of
transfusion home to doctors,” said Barr. “Transfusion carries an in-
herent danger. No transfusion should be given lightly. If a transfusion
is necessary, a full explanation (of the reasons, risks, and alternatives)
should be given to the patient.”
Barr, who successfully has defended San Francisco’s Irwin Memorial
Blood Bank in several cases, says that physicians who transfuse only
when medically indicated and who give full explanations during the
process of obtaining informed consent are “in good shape” even in those
instances in which blood does prove later to have been contaminated
with the HIV virus.
Now that blood screening procedures are in place, risks of transfusing
infected blood are diminished but not completely. Some say the chance
of getting AIDS from a blood transfusion today are as low as 1 in 500,000
but others put it at 1 in 50,000. Government statistics show only 12 AIDS
cases that reportedly were contracted through transfusions since blood
screening procedures were begun in 1985.
“I have tried 7 of 15 such cases against blood banks and I am convinced
that a jury can be made to understand that there was a time period when
people did not know about AIDS and did not know how to test blood
for the virus. I think these cases can be won. The problem is that people
have a great deal of sympathy for AIDS patients and they let their
emotions run away with them when making awards.”
Barr said he recently obtained a summary judgment in a case in which
three small boys in one family — all hemophiliacs — had contracted the
AIDS virus through contaminated blood products. “It was a tragic case.
But in such cases, nobody wins. The judge said to the family, ‘Sorry,
you don’t have a case here.’ But the blood bank(s) did not do anything
wrong.”
Barr suggested that federal solutions may be needed to help underwrite
the costs of care of such victims. He cited the vaccine compensation
program and the compensaton program for victims of black lung disease
as examples. “Blood banks cannot absorb the full social responsibility,”
he said. “They just don’t have enough money.”
Barr predicts that in 1991 some blood banks will declare bankruptcy in
NEW JERSEY MEDICINE N0
972
PROFESSIONAL LIABILITY
the wake of adverse judgments arising from AIDS suits. “One such
verdict can bankrupt a blood bank,” he said.
That is why blood banks increasingly are settling with plaintiffs and
letting much of the liability in AIDS cases flow through to physicians
and hospitals — a trend Barr thinks will continue. (Reprinted from Medi-
cal Liability Monitor, Winnetka, IL, Volume 15, Number 9, September
28, 1990.)
PROPER CARE NEEDED
TO AVOID SEXUAL
MISCONDUCT CHARGES
In order to prevent misunderstandings and protect physicians and pa-
tients from allegations of sexual misconduct during physical exami-
nations, the Board offers the following guidelines:
1. Maintaining patient dignity should be foremost in the physician’s
mind when undertaking a physical examination. The patient should be
assured of adequate auditory and visual privacy, and should never be
asked to disrobe in the physician’s immediate presence. Examining
rooms should be safe, clean, and well maintained, and equipped with
appropriate furniture. Gowns, sheets, and/or other appropriate apparel
should be made available to protect patient dignity while promoting a
thorough and professional examination.
2. A third party should be readily available at all times during a
physical examination. It is suggested that the third party actually be
present when the physician performs an examination of the sexual and
reproductive organs or rectum. It is incumbent upon the physician to
inform the patient of the option to have a third party present. This
precaution is essential regardless of physician/patient gender.
3. The physician should individualize his approach to physical
examinations so that the patient’s apprehension, fear, and embarrass-
ment are diminished as much as possible. An explanation of the neces-
sity of a complete physical examination, the components of that exami-
nation, and the purpose of disrobing may be necessary in order to mini-
mize the patient’s apprehension and possible misunderstanding.
4. The physician and his staff should exercise the same degree of
professionalism and caution when performing diagnostic procedures, i.e.
electrocardiograms, electromyograms, endoscopic procedures, radio-
logical studies, as well as surgical procedures and postsurgical followup
examinations when the patient is in varying stages of consciousness.
5. The physician should be alert to suggestive or flirtatious behavior
or mannerisms on the part of the patient, and should not put himself
in a compromising position.
6. The physician shall not exploit the physician/patient relationship
for sexual or any other purposes. Moreover, such an allegation against
a physician constitutes grounds for investigation on the basis of alleged
unethical behavior. (Reprinted with permission from the Ohio State
Medical Board and the Kentucky Board of Medical Licensure.)
Patient complaints of sexual misconduct by physicians are the most
sensitive and difficult cases the Board investigates. The incidents rarely
are witnessed. Allegations of sexual misconduct are particularly difficult
to prove, and can lead to public humiliation for both the patient and
the physician involved.
PROFESSIONAL James E. George, MD, JD, is the director of the Department of Pro-
L| ABILITY fessional Liability Control, and A. Ronald Rouse is director of special
projects, MSNJ. If you have questions, please call 609/896-1766.
VOL. 87— NUMBER 12 DECEMBER 1990
973
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974
NEW JERSEY MEDICINE
DECEMBER 1990 As I was writing this editorial, my thoughts turned to Thanksgiving, the
unique North American celebration that unites turkey and family, high-
lights cranberries and pumpkins, and intensifies the preparations for the
end-of-the-year holiday season. While other years have emphasized
shopping, this year should emphasize family.
The tens of thousands of American military personnel in the Middle East
are isolated from home and family. They do not know which to fear
more — boredom or Iraqi firepower — in a culture and climate totally
foreign to them. The ties to loved ones have been stretched to the limit.
Traditionally, December, in the past, has not produced peaceful actions
or cessation of hostilities, a lessening of tensions, or an increase in the
spirit of brotherhood between warring nations. Hanukkah celebrates the
victory of the Maccabees over Antiochus IV and the Syrians. Washington
led a secret crossing of the Delaware against the Hessians. The Germans
produced their last major offensive during World War II at the Battle
of the Bulge. The Chinese push at Christmas time in Korea is well
documented. And, let us remember Pearl Harbor.
The opposition of the nations of the world to the Iraqi invasion of Kuwait
is an unparalleled, near-unanimous response, making allies not seen
before in the history of the United Nations. The position of the United
States, supported by most of the rest of the world, deserves support by
all its citizenry. The protestors of today are not like those of a dozen
years ago; they are more like the American Firsters of depression days,
the ultra-isolationists of that era. They should be politely ignored. It is
in our better interest to be supportive, not just to the policies of our
government, but more particularly to our military and to the families
they left behind — especially during what should be a joyous time of year.
In December 1776, Thomas Paine wrote, “These are the times that try
men’s souls,’' and “The summer soldier and the sunshine patriot will,
in this crisis, shrink from the service of his country; but he that stands
it now deserves the love and thanks of man and woman.” Are we to be
sunshine patriots? Are we too sophisticated to honor God, family, and
country?
Happy holidays to you all. □
GUEST We are grateful to the dedicated members of the Subcommittee on
EDITORIAL: Maternal Mortality who have volunteered their time to review the 50
MATERNAL MORTALITY or ^ charts of pregnant women who die every year in New Jersey. Trying
to explain these tragedies often is thwarted by hospital records that are
difficult to read and carelessly written, with little or no effort to provide
an intelligible narrative of what took place. This arduous task of studying
the causes of maternal deaths is rewarded only by the satisfaction that
the information gathered and analyzed may possibly serve to prevent
the recurrence of similar tragedies. Unfortunately, this satisfaction is
tempered if not actually diminished by the sad realization that many
/OL. 87— NUMBER 12 DECEMBER 1990
975
of the physicians directly or indirectly involved may have learned little
or nothing from these events because most hospitals fail to conduct
meaningful discussions of maternal deaths. The obvious question arises:
how and why do hospital administrators, chiefs of departments
of obstetrics, medical society officers, and health department officials
allow this situation to continue? Suggestions by the MSNJ Subcommit-
teee on Maternal Mortality have been ignored. Decreases in the new
state budget will mean a decrease in the already meager surveillance
by the New Jersey State Department of Health. Are we waiting for
militant citizens to picket our hospitals or place advertisements in our
local newspapers?
The time has come for physician leadership. Every department of ob-
stetrics must have in place a protocol to be followed in the event of a
maternal death. There remains one effective remedy that the Committee
can prescribe to insure prompt action — the inclusion in future annual
reports of maternal mortality of the names of those hospitals where
formal discussions of maternal deaths fail to take place. Never before
has the old quotation been more pertinent: “Those who do not learn from
history are doomed to repeat it.” □ Jerome Abrams, MD, MPH
976
NEW JERSEY MEDICINE
BOOK
REVIEWS
ANNUAL REVIEW Annual Reviews, Inc., Palo Alto, CA, 1990. This year’s Annual Review
Qp MEDICINE of Medicine contains 46 different subjects related to the clinical sciences
and research topics. The practicing physician will enjoy reading papers
that are authoritatively written with a large number of references, and
reviewing black-and-white photographs and well-explained diagrams.
The variety of topics ranges from the pathogenesis and treatment of acne
to paroxysmal nocturnal hemoglobinuria. This excellent review should
be on one’s desk to be read whenever there is time, and certainly should
be a necessary reference text. □ Geobel A. Marin, MD
ASTHMA AS AN Paul M. O’Byrne (ed). Marcel Dekker, Inc., New York, NY, 1990. The
INFLAMMATORY therapy of asthma has changed markedly with the appreciation of
DISEASE asthma being an inflammatory disease. Emphasis has shifted to control
the chronic inflammatory component, rather than the bronchospastic
component, with avoidance and medications. This excellent and concise
book addresses asthma as an inflammatory disease. By discussing the
pathophysiology of inflammation in asthma, the book gives a clear
rationale how controlling the inflammation, therefore, will better control
the disease. The book discusses avoidance and elimination of inflam-
matory-inducing factors and gives strong emphasis on how to use medi-
cations to control inflammation. The role of allergy is discussed fully.
Since the book has only 312 pages, not all topics are covered completely.
Clinicians may desire more information on the pharmacological manage-
ment of asthma, both in the chronic and acute phases of the disease.
The book contains many references and charts.
I strongly recommend this book as a handy reference to anyone who cares
for asthmatic patients. It also is a fine introductory book for those not
as current with the new emphasis in asthma therapy. Medical students
will find this book helpful as it is easy to read. □ Harvey Weisslitz, MD
COMPREHENSIVE Harold A. Kaplan, MD, and Benjamin J. Sadock, MD. Baltimore, MD,
TEXTBOOK OF Williams & Wilkins, 1989. The fifth edition of this massive textbook
PSYCHIATRY aPPears only four years after the previous one. It is not significantly
larger but has been extensively rewritten and updated; 184 of the 237
contributors did not appear in the 1985 volume. The editors have at-
tempted to produce “the most thorough, complete, integrated, and re-
vised book of record of clinical psychiatry” and they have been successful
in this undertaking. It contains much more than psychiatry; its early
chapters are comprehensive but concise reviews of all aspects of neural
science pertinent to psychiatry, from neuroanatomy to basic molecular
genetic neuroscience. These chapters are followed by sections on neu-
rology, psychology, sociocultural sciences, quantitative and experimen-
tal methods, theories of personality and psychopathology, and psy-
chiatric interviewing. The contributors are outstanding scientists and
clinicians and the editors have worked hard to make their contributions
succinct yet lucid.
In an epilogue, Cancro states that the textbook was designed like a novel,
VOL. 87— NUMBER 12 DECEMBER 1990
979
BOOK REVIEWS
beginning with the first page and ending with the last. Most readers will
use this textbook for reference, and it probably is the best available
single work for this purpose. Residents who read it from cover to cover
will be prepared for Board examinations. □ A. Arthur Sugerman, MD
IMMUNOLOGY:
1 930-1980: ESSAYS ON
THE HISTORY OF
IMMUNOLOGY
This text contains a collection of essays written by renowned individuals
who have been instrumental in the development of major advances in
the field of immunology over the past 50 years. This text is not to be
taken as a history book, but does provide insights to the minds of some
of the major investigators that have influenced the course of immunology
as we know it today. □ Leonard Bielory, MD
INTRODUCTION TO
MEDICAL IMMUNOLOGY
G. Virella, J. Goust, H. Fudenberg (eds). The text, one of a series of
excellent volumes dedicated to one subject, is a thorough review of
immunology. Though one might claim an overall similarity of im-
munology topics for this and other texts, the clarity of writing clearly
places this book on a different level. In addition, the self-evaluation
questions found at the end of the chapters are a superb method for
novices interested in the field of immunology — to focus on the key points
of each chapter. Thus, the text has a superb potential as acting as a
text for medical students or other individuals interested in under-
standing the vast array of information that has been garnered under the
title of “immunology.” □ Leonard Bielory, MD
OXFORD TEXTBOOK OF
PSYCHIATRY,
SECOND EDITION
Michael Gelder, Dennis Gath, and Richard Mayou. New York, NY,
Oxford Medical Publications, 1989. This textbook is intended primarily
for psychiatric residents but also may be useful as a reference work for
medical students. Practicing psychiatrists and other physicians may
benefit from this concise and eminently readable volume. The authors
are the chairmen of the Department of Psychiatry at Oxford University.
Most of this up-to-date work is international in concept and well-bal-
anced with regard to American and British usage. Just as the first edition
(1983) used both the DSM III and ICD 9 classifications, the second
edition uses DSM IIIR and ICD 10 (draft). The double classification is
not available in any other textbook; it may be of great interest to some
readers and a distraction to others. I can recommend this textbook as
the best available for those who want a readable middle-sized book (just
over 1,000 pages) presenting the practice of psychiatry as it is today.
□ A. Arthur Sugerman, MD
TEXTBOOK OF
INTERNAL MEDICINE
William N. Kelly, MD. J.B. Lippincott Company, Philadelphia, PA,
1989. Kelly’s Internal Medicine is bound to become a favorite textbook
among the classics in the group. This book is a gold mine of medical
information compiled by some of the best known names in American
medicine; it is written and printed so every chapter fully satisfies the
need of the physician looking for information. There are no weaknesses
here. I devoted my reviewing time to reading the sections on
gastroenterology, infectious disease, and cardiology. I then reviewed the
index and looked up entities such as ehrlichiosis and babesiosis and was
gratified to see them clearly listed and indexed.
I am convinced this textbook will be a standard source of consultation,
not only for the physicians who practice internal medicine, but also for
the specialists who need to find a quick and authoritative source of
information. I enjoyed browsing through this book and reading several
of its chapters; I am certain I will refer to it frequently. I recommend
it highly and expect to make it my standard textbook in internal medi-
cine. □ Geobel A. Marin, MD
980
NEW JERSEY MEDICINE
Professional Review
and Regulations
JAMES E. GEORGE, MD, JD
MADELYN S. QUATTRONE, JD
JOANN PHILLIPS, CMSC
New federal and state legislation will subject physicians to increasing scrutiny
in the 1990s. This article highlights these new laws and explores physician
concerns about them.
Physician regulations and review of the qual-
ity of health care will take on a new dimen-
sion in the 1990s. The professional conduct
of physicians will undergo increasing scrutiny as a
result of new federal and state laws. The Health
Dr. George is president, Emergency Physician As-
sociates, PA; a partner in the law firm of George & Korin,
Woodbury; and director of the Department of Liability
Control, Medical Society of New Jersey. Ms. Quattrone
is a partner in the law firm of George & Korin. Ms. Phillips
is credentialing coordinator, Emergency Physician As-
sociates, PA. The paper was submitted in June 1990 and
accepted in July 1990. Requests for reprints may be
addressed to Dr. George, George & Korin, P.O. Box 319,
Woodbury, NJ 08096.
Care Quality Improvement Act, signed by former
President Reagan in 1986, promotes professional re-
view activities. It also sets standards for professional
review actions and grants broad immunity to re-
viewers as an incentive and protection for physicians
engaging in effective professional peer review. This
same federal legislation also authorized the creation
of the National Practitioner Data Bank to collect
and release to eligible parties certain adverse infor-
mation relating to the professional competence and
conduct of physicians, dentists, and other health
care providers.
New Jersey physicians also will be subject to the
Professional Medical Conduct Reform Act of 1989
VOL. 87— NUMBER 12 DECEMBER 1990
983
(Act), signed into law by former Governor Kean on
January 12, 1990. The new law strengthens the sys-
tem for monitoring and disciplining physicians and
podiatrists in this state and makes fundamental
changes in the law governing physician review and
discipline. This article highlights some important
aspects of the new federal and state laws and ex-
plores physician concerns about them.
THE NATIONAL PRACTITIONER DATA BANK
Although the Health Care Quality Improvement
Act (HCQIA) was enacted in 1986, federal regu-
lations for the Data Bank were not published until
October 1989. The regulations require hospitals,
health care entities, boards of medical examiners,
professional societies, individuals, and professional
liability insurance companies to report certain
adverse information to the National Practitioner
Data Bank. The information includes adverse
licensure actions, adverse actions regarding clinical
privileges, professional society memberships, and
payments resulting from settlement or judgments of
malpractice claims and suits, including a descrip-
tion of the acts or omissions and injuries and ill-
nesses or injuries upon which the suit or claim was
based. However, the regulations provide that a pay-
ment in settlement of a malpractice suit or claim
shall not be construed as creating a presumption
that malpractice occurred.
HCQIA also requires a hospital to request infor-
mation from the Data Bank whenever a physician
applies for clinical privileges or a staff position. At
least every two years hospitals also must request
information from the Data Bank concerning each
practitioner who maintains clinical or staff privi-
leges (courtesy or otherwise) at the hospital.
The regulations also require that adverse infor-
mation be reported promptly to the Data Bank.
Malpractice payments and adverse licensure actions
must be reported to the Data Bank within 30 days
of payment or the date licensure action was taken.
Hospital and health care entities must submit
adverse actions to the New Jersey State Board of
Medical Examiners (SBME) within 15 days from
the date the adverse action was taken. SBME, in
turn, must report such adverse information to the
Data Bank within 15 days.
A “health care entity” is defined as any organiza-
tion providing health care services and employing a
formal peer review process to further qualify health
care. A hoard of medical examiners in the state in
which the reviewing health care entity is located
must receive the following adverse actions by health
care entities regarding clinical privileges: a) any pro-
fessional review action that adversely affects the
clinical privileges of a physician for more than 30
days; and b) the acceptance by a health care entity
of the surrender of clinical privileges or any restric-
tion of such privileges while the physician is under
investigation by the health care entity relating to
possible incompetence or improper professional con-
duct or the surrender of clinical privileges in return
for not conducting such an investigation or proceed-
ing.
Likewise, certain adverse actions taken by a state
board of medical examiners must be reported to the
National Practitioner Data Bank. Adverse actions
are any actions based on reasons relating to pro-
fessional competence or conduct that (a) revokes or
suspends or otherwise restricts a physician’s license;
(b) censures, reprimands, or places a physician on
probation; or (c) results in surrender of a physician’s
license.
The federal regulations also provide sanctions for
failure to report. If payments made in settlements
of malpractice suits or claims are not reported, civil
monetary penalties of up to $10,000 for each such
payment may be assessed. Where the secretary of
Health and Human Services determines that a state
board of medical examiners or health care entity has
failed to submit a required report, the secretary will
designate another qualified entity to make such re-
ports.
Information reported to the Data Bank is con-
fidential, but the regulations provide for limited dis-
closure. Hospitals must access the Data Bank when-
ever a physician applies for staff or clinical privileges
and also must access the Data Bank every two years
for information concerning any physician who has
staff or clinical privileges. Hospitals may request
access at any other time.
Under certain limited circumstances, Data Bank
information may be made available to plaintiffs or
their attorneys in medical malpractice cases. A
plaintiff attorney (or plaintiff representing himself)
who has filed a malpractice suit against a hospital,
may request information about a specific physician,
dentist, or other health care practitioner who also is
named in the legal action. However, this information
will be disclosed only upon the submission of
evidence that the hospital failed to access the Data
Bank as required by law concerning that physician.
The federal regulations also provide a mechanism by
that a physician may dispute Data Bank infor-
mation concerning himself.
NJ PROFESSIONAL MEDICAL CONDUCT
REFORM ACT OF 1989
This new state law significantly strengthens re-
porting requirements by health care facilities,
HMOs, medical malpractice insurers, and health
care practitioners. Qualified immunity also is
provided to those required to report.
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984
NEW JERSEY MEDICINE
The new state law also authorized the establish-
ment of a nine-member medical practitioner review
panel, effective July 11, 1990. The panel’s function
is to “promptly” investigate information provided to
it and to make recommendations and referrals to
SBME. Eight members of the panel are appointed
by the governor with the advice and consent of the
Senate. Four physicians, three “consumers” of
health care services, one hospital administrator, and
one member of SBME, appointed by the Board
president, shall serve on the panel.
The new law also created a position of fulltime
medical director of SBME and provides for com-
puterization of all Board operations. Increased
licensing fees will fund the costs of the new Board
positions and Panel.
Highlights of the Act are as follows: Criminal
sanctions are provided under two sections of the law.
Under Section 14 of the Act, a person who knowingly
practices medicine or podiatry without a license is
guilty of a crime of the third degree. Under Section
15 of the Act, a licensee is guilty of a crime of the
fourth degree “if he purposefully destroys, alters, or
falsifies any record relating to the care of a medical
or surgical or podiatric patient in order to deceive
or mislead any person as to information, including
but not limited to a diagnosis, test, medication,
treatment, or medical or psychological history, con-
cerning the patient.”
New Jersey classifies criminal offenses into four
degrees for the purpose of sentencing. The maximum
fine that can be imposed for either a third or fourth
degree offense is $7,500 or any higher amount equal
to double any monetary gain to the offender or loss
to the “victim.”
A person convicted of a third-degree crime may
be sentenced to prison for a term between three and
five years. For a fourth degree crime the term shall
not exceed 18 months. Any of these sentences (im-
prisonment or fines) may be suspended at the discre-
tion of the court.
The new law also contains a provision that re-
quires practitioners to promptly notify SBME of
“information which reasonably indicates another
practitioner has demonstrated an impairment, gross
incompetence or unprofessional conduct which
would present an imminent danger to an individual
patient or to the public health, safety or welfare.”
A practitioner who fails to notify the Board is subject
to disciplinary action and civil penalties. However,
no private right of action may be brought by a third
party against a practitioner for failure to report.
Also, a practitioner who gains such knowledge as a
result of rendering treatment to the subject practi-
tioner is exempt from reporting.
Practitioners, HMOs, and health care facilities
that report to the Board are granted immunity for
damages, so long as the reporting party has not
knowingly provided false information.
Other new state reporting requirements mandate
that health care facilities and HMOs notify the re-
view panel of the following acts: a) voluntary resig-
nation when the practitioner’s conduct or patient
care is being reviewed or an intention to do so has
been expressed; b) voluntary relinquishment of any
clinical privileges if the practitioner’s conduct or
patient care is being reviewed or an intention to do
so has been expressed; c) summary or temporary
suspension or revocation of privileges or discharge
from the staff, as well as the termination of a pro-
fessional services contract “for reasons relating to
the practitioner’s incompetency, misconduct or im-
pairment”; d) voluntary agreement by the physician
to the placement of conditions or limitations on the
exercise of clinical privilege or practice within the
health care facility or HMO; e) granting of a leave
of absence from a health care facility or HMO if the
reasons provided by the practitioner to support the
leave relate to any physical, mental, or emotional
condition or drug or alcohol use, that might impair
the practitioner’s ability to practice with reasonable
skill and safety.
The new state law requires professional liability
insurance carriers to report all medical malpractice
settlements, judgments, and arbitration awards, re-
gardless of dollar amounts, to the medical practi-
tioner review panel. Insurers also are required to
report any termination or denial of coverage to a
practitioner or surcharge assessed on account of the
practitioner’s practice method or medical malprac-
tice claims history. However, the review panel and
the Board shall not presume that any judgment or
award in a malpractice case is conclusive evidence
in any disciplinary proceeding. The fact that a dis-
puted claim or suit has been settled is not admissible
in any disciplinary proceeding.
IMMUNITY FOR PEER REVIEW AND REPORTING
In enacting HCQIA, Congress identified and re-
sponded to an over-riding national need to provide
incentive and protection for physicians engaging in
effective professional peer review.
If a professional review action meets the standards
specified in HCQIA, a broad grant of immunity from
liability is provided to the reviewing body, all mem-
bers or staff of the reviewing body, any person under
contract or other formal agreement with the review-
ing body, and any person who participates or assists
the body with respect to any action, including per-
sons who provide information to the reviewing body,
whether witnesses or otherwise.
This broad grant of immunity protects against
liability under virtually any federal and state law,
with a few exceptions. Civil rights violations are not
VOL. 87— NUMBER 12 DECEMBER 1990
985
protected by immunity. Immunity under HCQIA
does not extend to persons who knowingly provide
false information to a professional review body.
To qualify for immunity under HCQIA, peer re-
view actions must meet standards specified under
Section 1112 of the Act. These include specific due
process rights that must be afforded to the involved
physician before any rights or interests can be inter-
fered with or taken away. Fundamental fairness re-
quirements of HCQIA mandate that peer review be
done in good faith with the goal of improving the
quality of health care. Immunity is removed where
peer reviewers are in direct economic competition
with the involved physician whose conduct is being
reviewed. In addition, the involved physician must
be given adequate notice of a hearing (30 days), the
right to representation at the hearing, as well as the
opportunity to present evidence and to call and cross
examine witnesses. When review is conducted ap-
propriately, the risk of liability is minimal.
The immunity granted by HCQIA is immunity
from damages. The law does not prevent peer re-
viewers from being sued. However, another provision
of HCQIA does provide an economic disincentive to
reduce the chances of reviewers being sued by an
aggrieved physician. An aggrieved physician who
sues and loses may be required to pay the costs of
the reviewers’ defense, if the claim or conduct of the
disgruntled physician during the litigation “was friv-
olous, unreasonable, without foundation or in bad
faith.”
The New Jersey law also provides a grant of im-
munity for peer review activities. The Professional
Medical Conduct Reform Act of 1989 amends
N.J.S.A. 2A:84A-22.10 and provides immunity for
peer review activity taken without malice and in the
reasonable belief after reasonable investigation that
such action or recommendation is warranted upon
the basis of the facts disclosed.
CONFIDENTIALITY
Information reported under HCQIA is considered
confidential and civil monetary penalties of up to
$10,000 may be assessed for each violation of con-
fidentiality. The HCQIA confidentiality provisions
do not apply to the original documents or records
from which the reported information is contained.
Disclosure of information reported to HCQIA may
lawfully occur under certain circumstances. For ex-
ample, when a plaintiff s attorney sues a physician
as well as the hospital where the physician has
clinical privileges, the plaintiffs attorney may probe
the hospital’s knowledge about the physician. If the
hospital has failed to obtain the Data Bank infor-
mation it is required to request under HCQIA, the
malpractice plaintiff may request access to the Data
Bank information on the physician involved.
Whether New Jersey law prohibits disclosure of
peer review information is unclear. N.J.S.A.
2A:84A-22.8 generally prohibits disclosure of infor-
mation and data secured by and in the possession
of utilization review committees established by any
certified hospital or extended care facilities in the
performance of their duties. In 1975, a state lower
court interpreting this statute held that its provision
of confidentiality is not to be broadened to include
all peer review committees. It held that N.J.S.A.
2A:84A-22.8 does not prevent a plaintiffs attorney
from discovery of records compiled by a medical
records and audit committee, tissue committee, in-
fection control committee, or a medical council, so
long as they relate to the patient-plaintiff incidents
allegedly the subject matter of a malpractice suit
(Young versus King, 136 N.J. Super 127 [Law Div.
1975]).
In 1985, the New Jersey Supreme Court re-
cognized a qualified privilege of self-examination or
privilege of self-critical analysis as furthering the
public interest. The state’s highest court recognized
that disclosure of the materials involved in an
internal investigation into health care service in-
vokes serious and important questions of public pol-
icy that courts carefully must consider. Parties seek-
ing disclosure of such information will be required
to demonstrate a need for such discovery that
outweighs the investigative agency’s need for con-
fidentiality and privacy. (McClain versus College
Hospital, 99 N.J. 346 [1985]).
The court’s approach to whether peer review ma-
terials may be disclosed is a balancing process that
will be applied on a case-by-case basis.
COMMENTARY
Will the new federal and state laws achieve the
desired result of assuring quality health care while
protecting those who engage in appropriate peer re-
view? Will the laws result in increased litigation by
physicians who are adversely affected by peer re-
view? Will these requirements of reporting settle-
ments result in more malpractice cases going to
trial? Will the federal law result in more suits that
include hospitals as defendants? Will the fact that
the federal government maintains a lifetime record
of adverse actions taken against a physician, while
ignoring positive contributions to the profession and
the public, really weed out incompetent physicians?
The long-range positive and negative ramifica-
tions of the new carrot-and-stick approach to phy-
sician regulation in the 1990s will take a decade to
truly assess. Peer review bodies and medical so-
cieties should scrutinize their bylaws and practices
to ensure conformity with the requirements of
HCQIA and the Act, to ensure immunity from lia-
bility for good faith peer review. ■
986
NEW JERSEY MEDICINE
Professional Medical
Conduct Reform Act
SEAN PATRICK MURPHY, JD
A new law significantly increases the regulation of New Jersey physicians
and heightens the State Board of Medical Examiners scrutiny of potentially
impaired and incompetent physicians. The law is a comprehensive ex-
pansion of New Jersey’s physician peer review.
On January 13, 1990, former Governor
Thomas Kean signed into law the Pro-
fessional Medical Conduct Reform Act of
1989 (Act).1 The Act, one of the most significant
health legislative enactments in the state’s history,
redefines the mechanism for dealing with potentially
impaired or incompetent physicians and replaces
the existing voluntary program operating under the
auspices of MSNJ with a comprehensive regulatory
initiative organized under the physician licensing
authority, the New Jersey State Board of Medical
Examiners (SBME).
Mr. Murphy is an attorney with Nash & Company, Pitts-
burgh, PA. Requests for reprints may be addressed to
Mr. Murphy, Nash & Company, 700 Westinghouse Build-
ing, Pittsburgh, PA 15222.
The Act strengthens existing reporting laws and
establishes new reporting requirements, making it
more likely that SBME will be informed and in-
volved in matters of impairment and incompetency.
The Act will impact every physician in the state of
New Jersey.
BACKGROUND
The vast majority of New Jersey’s physicians are
competent, caring professionals devoted to their pa-
tients and dedicated to medicine. Despite this, it has
been reported that between 3 and 16 percent of the
physicians in New Jersey are impaired; “unable to
properly or safely practice medicine because of al-
coholism, other drug abuse, mental illness, senility,
or a disabling condition.”2 Approximately 10 percent
VOL. 87— NUMBER 12 DECEMBER 1990
989
are reported to be incompetent, meaning that they
lack “sufficient knowledge, skills, or judgment to
adequately practice medicine.”2
New Jersey has been a recognized leader in con-
fronting these problems. In 1977, MSNJ established
the Impaired Physicians Committee, replaced in
1982 by the Impaired Physicians Program (IPP), a
volunteer, nonpunitive program that “identifies,
confronts, and refers for treatment physicians im-
paired by alcoholism, drug abuse, mental illness,
senility, or disabling injury or disease.”2 In 1983, the
submitted notice of a malpractice award to SBME.2 ®
A common thread throughout the Report is the
lack of data sharing for dealing with these problems. :t
The Report noted that SBME does not have enough
information on physicians who may be impaired or ,e
incompetent along with inadequate methods of cc
identifying these physicians.
In response to these concerns, the Report de- a
veloped a series of conclusions and specific rec- I P1
ommendations, many of which have been incor- 111
porated into the Act. The following summarizes the P1
| hi
ei
The Act strengthens existing reporting laws and establishes
new reporting requirements , making it more likely that SBME will
be informed and involved in matters of impairment and in-
competency. The Act will impact every physician.
it
New Jersey Legislature passed a series of reporting
laws requiring health care facilities and insurance
companies to notify SBME of actions that could
indicate potential impairment or incompetence.3
More recently, Congress passed the Health Care
Quality Improvement Act of 1986, a federal law that
mandates the reporting of such physicians to the
National Practitioner Data Bank.4 Yet the problem
of impaired and incompetent practitioners still ex-
ists, both in New Jersey and the nation.
In October 1987, a State Commission of Investiga-
tion (SCI) issued a report and recommendations on
impaired and incompetent physicians (the Report).2
The Professional Medical Conduct Reform Act is a
direct result of the findings of the Report.
THE SCI REPORT
The SCI Report noted that the IPP, either stand-
ing alone or in conjunction with the existing report-
ing laws, cannot adequately remedy the problem. It
stated that the IPP lacks the resources to investigate
adequately complaints and followup on enrolled
clients; lacks the statutory authority to sanction
dangerous practitioners; and is unable to objectively
monitor problem physicians since the IPP is a phy-
sician-sponsored program.2
New Jersey’s reporting laws also were deemed in-
adequate. The prior law requiring hospitals to report
disciplinary proceedings against such physicians has
failed in part, due to general noncompliance and the
existence of capricious loopholes, e.g. informal and
“voluntary” action on the part of the health care
facility was not deemed a “reportable event.”2 The
law requiring insurers (including self-insuring phy-
sicians) also has failed; not one physician has ever
9 a
significant aspects of the Act, reflecting New Jer- n
sey’s scrutiny of health care professionals.
THE PROFESSIONAL MEDICAL
CONDUCT REFORM ACT
The Professional Medical Conduct Reform Act is tl
a series of new laws and amendments that can be t
classified into one of the following four categories:
provisions designed to improve and correct reporting i
deficiencies; restructuring SBME to respond to the n
problem; facilitating the flow of information on im- p
paired and incompetent practitioners; and enforce- ii
ment of standards and sanctions. j
Improving and Correcting Reporting Deficien-
cies. The Act significantly increases the likelihood ‘
that SBME will be notified of health care practi- n
tioners who are, or may be, impaired or incompetent
by closing a number of loopholes that existed in the It
old reporting laws. Perhaps the most significant h
change in this regard is the modification of the law
requiring health care facilities (including HMOs) to h
notify SBME of disciplinary proceedings taken (
against physicians.
The Act expands the existing reporting law to (
require health care facilities to report other events,
such as when a practitioner voluntarily resigns from
staff (if that practitioner was under review for im-
pairment or incompetency); voluntarily relinquishes
partial privileges while under review; has full or
partial privileges temporarily or summarily revoked;
agrees to limitations on clinical privileges; is granted
a leave of absence if it relates to impairment or
incompetency; or is a party to a suit in which the
facility also is a party and in which there is a settle-
ment, judgment, or award.5 The reporting require-
990
NEW JERSEY MEDICINE
ments also have been expanded to include not only
physicians with privileges, but also medical resi-
dents, interns, and podiatrists (“practitioners”).6
Medical staffs and health care facilities now must
review their current bylaws and procedures to ensure
compliance with these changes, and with a view
toward what procedures, due process and otherwise,
can and should be provided to potentially affected
practitioners. Medical staffs that currently use infor-
mal means to identify and correct problems of im-
paired and incompetent practitioners no longer will
be able to avoid notification to SBME of these situ-
ations. Hospital administrators also now must re-
evaluate their current notification policies and
procedures to make certain that notification to
SBME is both made and done so in a timely manner;
otherwise the facility may be subject to the in-
creased sanctions found in the Act.
The Act modifies the current law that requires
insurance companies to notify SBME.7 Now, in-
surance companies must notify SBME in writing of
any medical malpractice claim, settlement, judg-
ment, or arbitration award, not merely those matters
over $25,000. The Act also provides that the practi-
tioner’s insurer now must notify the review panel in
writing of any termination or denial of coverage to
the practitioner or surcharge assessed on account of
the practitioner’s practice method or medical prac-
tice claims history.8
The Act also requires practitioners to notify
directly SBME if they are “in possession of infor-
mation which reasonably indicates that another
practitioner has demonstrated an impairment, gross
incompetence, or unprofessional conduct which
would present an imminent danger to an individual
patient or to the public health, safety or welfare.”9
Now, a practitioner’s duty to report an impaired or
incompetent colleague is not simply grounded in
medical ethics, but in statutory law. Practitioners
that fail to report in these situations could be subject
to both civil penalties and licensure sanctions.9
Simply stated, the Act tightens up loopholes in
existing reporting requirements to increase the flow
of information to SBME, enabling it to better iden-
tify situations in which a practitioner may be in-
competent or impaired.
Restructuring SBME To Respond to the Prob-
lem. Collecting information on practitioners who
may be impaired or incompetent is one aspect;
having a system in place to process this information
and address the problem is another. The Act restruc-
tures SBME to provide it with both a mechanism
and the financial resources to address problems of
impaired and incompetent petitioners.
The Act requires SBME to establish a medical
practitioner review panel to receive notification of
reportable events and other complaints concerning
impaired and incompetent practitioners.10 The re-
view panel shall consist of members appointed by
the Governor: four physicians; three consumers; one
administrator of a hospital appointed upon the rec-
ommendation of the New Jersey Hospital Associa-
tion;10 and one SBME member.
The review panel shall investigate information re-
ceived regarding impaired and incompetent practi-
tioners and recommend to SBME one of the follow-
ing: that the affected practitioner be referred to the
attorney general for disciplinary action; that the
matter be deferred pending litigation or action by
the health care facility; that the practitioner be re-
ferred to a treatment program; or that no action is
warranted. SBME then may affirm, reject, or mod-
ify the recommendations of the review panel.11
The Act also establishes that SBME shall employ
a full-time medical director, a licensed physician
who is knowledgeable about, or who has clinical ex-
perience in, chemical dependency or addiction-
oriented psychiatry. The medical director shall be
charged with reviewing complaints, assisting the re-
view panel in making its dispositions, and assisting
SBME in making disciplinary determinations re-
garding the practitioner’s license.12
These structural changes to SBME are an essen-
tial starting point for the Professional Medical Con-
duct Reform Act to achieve its intended goal of
identifying problem practitioners through an orderly
process. However, SBME must be certain to extend
itself beyond its traditional punitive role with regard
to these matters. It must provide a constructive
forum for rehabilitation so that practitioners have a
fair opportunity to be integrated again into the
medical profession.
Facilitating the Flow of Information. Another
characteristic of the Act is that it facilitates the flow
of information about practitioners. It increases the
likelihood that SBME will receive information that
may identify a problem practitioner and enables
SBME to notify directly health care facilities and
fellow practitioners with whom the affected practi-
tioner is directly associated.
The Act requires that practitioners provide SBME
with specific information concerning health care fa-
cilities in which they have privileges, and that they
identify the names and addresses of other practi-
tioners with whom they are directly associated.13
This will enable SBME to notify these interested
third parties when SBME has suspended or other-
wise limited a practitioner’s license and followup on
any practitioner against whom it has taken dis-
ciplinary action. SBME now will be able to monitor
interns and residents; it will issue permits to such
practitioners that will define the permissible scope
of practice while in training; and provide a mecha-
nism to monitor them.14
VOL. 87— NUMBER 12 DECEMBER 1990
991
New Jersey also is mandating that health care
facilities maintain and retain records of “all com-
plaints about and disciplinary proceedings or actions
against a practitioner who has an affiliation with the
health care facility or health maintenance organiza-
tion,”15 as well as records relating to mortality,
morbidity, complication, infection, and readmission
experience.”16 The collection and maintenance of
this information is consistent with the ever-increas-
ing emphasis on health care quality assessment.
This information will be useful at the micro level
with regard to particular practitioners, and at the
macro level with regard to the New Jersey State
Department of Health as it attempts to measure the
quality of medical services rendered at various
health care facilities.
Enforcement Standards and Sanctions. The Act
also clearly defines the standard of proof required
before SBME can revoke a practitioner’s license. It
states that SBME “may refuse to grant or may
suspend or revoke a license . . . upon a showing of
the preponderance of credible evidence that the
holder of such license has demonstrated any physi-
cal, mental, or emotional condition or drug or al-
cohol use which impairs his ability to practice with
reasonable skill or safety.”17
The “preponderance of the credible evidence”
standard of proof is the lowest level of legal proof,
meaning that SBME must merely have evidence
that demonstrates, more probably than not, that the
affected practitioner is unable to practice medicine
safely. If SBME is unable to meet this burden of
proof, the practitioner would have independent
grounds on which to appeal SBME’s actions. This
standard of proof is an improvement over the prior
subjective standard that simply required proof to the
satisfaction of SBME.
The Act certainly strengthens the state’s power to
sanction persons (including criminal sanctions) and
entities that fail to comply with the reporting re-
quirements or other provisions of the Act. The
enhanced sanctions increase the likelihood of com-
pliance and increase the likelihood that the Act will
remedy the reporting infirmities earlier identified in
the SCI Report.
CONCLUSIONS
The Act, including mandatory reporting require-
ments by health care facilities and the establish-
ment of the review panel, took effect on July 11,
1990. It is too early to draw any definitive con-
clusions about the actual impact of the Act. The
focus at this point should be on education and com-
pliance.
The New Jersey State Department of Health re-
cently promulgated regulations intended to track
the requirements of the Act. These regulations
should be scrutinized by all since they do not cur-
rently reflect all of the “11th hour” changes that
were made to the Act just prior to its passage.
Once the review panel becomes fully operational,
it is likely that there will be a substantial increase
in the number of practitioners reported to SBME for
problems of impairment or incompetency. However,
many practitioners still are going to be reticent
about reporting colleagues. This is understandable
considering SBME is the state’s licensing authority
for physicians.
SBME is going to have to demonstrate that it is
not merely a punitive organization. It should af-
firmatively demonstrate that it also is a forum for
rehabilitation. It should make every reasonable and
fair effort to try to rehabilitate practitioners before
taking the next step of limiting, reducing, or revok- p
ing their licenses.
From a larger perspective, the Act continues the ^
statewide and, for that matter, nationwide focus on f(
peer review. It provides a new mechanism to coordi-
nate information from many different sources and
ultimately directs it to a single source, SBME, for
scrutiny. The centralization of this information also
lays the groundwork for state and local programs
that routinely will assess and monitor the variations
of the quality and cost of health care from one fa-
cility to another.
The medical profession must remain vigilant dur- f
ing this time of rapid change. Physicians and medi-
cal staffs must make certain that they actively par-
ticipate in the process of decision making to assure
that they are partners in the design of these changes, 3
and not merely the subjects of them. ■
REFERENCES
1. N.J. Stat. Ann. §45:9-19.4 (West Supp. 1989).
2. State of New Jersey Commission of Investigation,
Reports and Recommendation on Impaired and Incompe-
tent Physicians. (Oct. 1987).
3. N.J. Stat. Ann. §26:2H-12.2 (West 1983); N.J. Stat.
Ann. §17:30D-17 (West 1983).
4. Health Care Quality Improvement Act of 1986,
Pub.L. No. 99-160, 100 Stat. 3784 (codified at 42 U.S.C.
§§11101-11152) (amended by Public Health Service
Amendments of 1987, Pub.L. No. 100-177, 101 Stat. 986)
[hereinafter HCQIA],
5. N.J. Stat. Ann. §26:2H-12.2 (West Supp. 1989).
(
I
6. N.J. Stat. Ann. §26:2H-12.2(f) (West Supp. 1989).
7. N.J. Stat. Ann. §17:30D-17 (West Supp. 1989).
8. N.J. Stat. Ann. §17:30D-17(b) (West Supp. 1989).
9. N.J. Stat. Ann. §45:9-19.5 (West Supp. 1989).
10. N.J. Stat. Ann. §45:9-19.8 (West Supp. 1989).
11. N.J. Stat. Ann. §49:9-19.9 (West Supp. 1989).
12. N.J. Stat. Ann. §45:9-19.6 (West Supp. 1989).
13. N.J. Stat. Ann. §45:9-19.7 (West Supp. 1989).
14. N.J. Stat. Ann. §45:9-19.12 (West Supp. 1989).
15. N.J. Stat. Ann. §26:2H-12.2(a) (West Supp. 1989).
16. N.J. Stat. Ann. §26:2H-12.2(b) (West Supp. 1989).
17. N.J. Stat. Ann. §45:9-16 (West Supp. 1989).
992
NEW JERSEY MEDICINE
Maternal Deaths in
New Jersey: 1 988
GERARD F. HANSEN, MD, MPH
RONALD A. CHEZ, MD
Physicians reported 56 maternal deaths in New Jersey in 1988. AIDS, adult
respiratory distress syndrome, and trauma were dominant causes of ma-
ternal demise. There continues to be value in reviewing maternal deaths. The
authors detail a model protocol.
The Subcommittee on Maternal Mortality
was established as a division of the Maternal
and Child Care Committee of the Medical
Dr. Hansen is associate professor of clinical obstetrics
and gynecology at UMDNJ-New Jersey Medical School
and Dr. Chez is professor, Department of Obstetrics and
Gynecology, University of Florida, Tampa. This article is
the result of the work of the members of the Subcommit-
tee on Maternal Mortality and of the New Jersey State
Department of Health: James P. Thompson, MD, chair-
man; Joseph DeStefano, MD; Steven Feld, MD; William
Hartko, MD; Robert Malatesta, MD; Thomas Noone, MD;
Joseph Saladino, MD; Nicholas Salerno, MD; Ronald A.
Chez, MD; Gerard F. Hansen, MD; as well as consultants:
Artist Parker, MD; George Halpin, MD; Mackrim Irian,
MD; and Roberta McDonough, RN. This paper was sub-
mitted in June 1990 and accepted in July 1990. Requests
for reprints may be addressed to Dr. Hansen, UMDNJ-
New Jersey Medical School, 185 South Orange Avenue,
Newark, NJ 07103.
Society of New Jersey for the purpose of investigat-
ing all deaths of pregnant women in our state each
year. The information gained is used in an educa-
tional effort to prevent recurrences of preventable
conditions. The Maternal and Child Health Pro-
gram of the New Jersey State Department of Health
assists this Subcommittee by collecting data. This
joint effort of NJDOH personnel and a committee
of MSNJ shows how public and private sectors of
the health care team can work together to decrease
maternal mortality.
RESULTS
There were 117,500 live births in New Jersey in
1988. Reports of 56 pregnant women who died were
submitted to the Subcommittee for investigation.
The members of the Subcommittee represent all
areas of the state and are expected to know of ma-
VOL. 87— NUMBER 12 DECEMBER 1990
995
Table 1. Classification and mortality rates.
Live Births in 1988
Maternal Deaths Reported
Nonmaternal
Maternal
Rate (indirect only)
Rate (direct only)
Rate (all causes)
Maternal
117,500
56
16
22
19/100,000 live births
15/100,000 live births
48/100,000 live births
34/100,000 live births
i
(
*9
Pc
ternal deaths occurring in their counties that might
not have been tabulated properly. The 1988 data are
considered accurate because the present death
certificate requires an indication to whether the de-
ceased was pregnant at the time of death.
Table 1 lists the classification and mortality rates
using the reporting format suggested by the Ameri-
can College of Obstetricians and Gynecologists. The
remaining statistical data are summarized in Tables
2 through 5.
A nonmaternal death is the death of a woman
from causes not related to pregnancy or its manage-
ment. The 16 nonmaternal deaths were due to drug
abuse (6), automobile accident (6), homicide (3),
and suicide (1). This reflection of the social problems
facing our society is startling. Cocaine was found in
all drug abuse-related deaths. Alcohol use by the
victim or victimizer was a primary contributor in the
vehicular deaths. The homicides and suicide ap-
parently were incidental to the pregnancy state.
An indirect maternal death is an obstetrical death
resulting from previously existing disease or a dis-
ease that develops during pregnancy, labor, or the
puerperium that is not directly due to changes of
pregnancy. There were 22 deaths: 17 indirect
deaths and 5 preventable deaths. One patient was
diagnosed with systemic lupus erythematosus at 8
weeks’ gestation. She was transferred to a tertiary
care unit at 24 weeks’ gestation in respiratory dis-
tress with untreated severe preeclampsia of 2 days’
duration. Earlier referral and more aggressive man-
agement of her respiratory problem might have
prevented this tragedy. One patient with chronic
lung disease and another with aortic stenosis would
have benefited by more aggressive medical care.
Three patients died as a result of adult respiratory
distress syndrome (ARDS). In each instance, an .
aspiration pneumonia either was undetected or un-
recorded. The treatment of developing ARDS re-
quires intensive care delivered by a multi- Pi
disciplinary team. This usually is accomplished in
a unit having a qualified intensive care specialist to
coordinate all aspects of care.
A direct maternal death is an obstetrical death
due to complications of pregnancy, labor, or U
puerperium and from intercessors, omissions, incor-
rect treatment, or from a chain of events resulting
from one of these complications. There were 18 such I'd
deaths, 9 deaths that were judged to be preventable, j
and 9 deaths judged to be nonpreventable. Two pa- .
tients died of ARDS secondary to a delay in the
diagnosis of ectopic pregnancy with resulting
hypotension and hypoxia. Failure to appreciate the :
possibility of a splenic artery aneurysm and to per-
form an exploratory laparotomy promptly led to 1
maternal death. One patient died of sepsis while
being treated aggressively with the wrong antibiotic.
Several studies showed the organisms to be
enterococci and Clostridium tertium, both treatable
with penicillin or ampicillin. Anesthesia was a con-
tributing factor in 3 deaths. In each case, proper
intubation was not performed or the patient was not
monitored carefully until she was fully reactive and
suffered a resultant hypoxic episode that could not
be reversed. One patient died of hemorrhage second-
ary to a placenta accreta treated with a
supracervical hysterectomy when a complete hys-
terectomy was needed; a hemothorax secondary to
a misplaced Swan-Ganz catheter also was a factor
in this death.
NEW JERSEY MEDICINE
996
Table 2. Characteristics of maternal deaths by race,
age, and prenatal care.
Race
Number
Percent
White
24
43
Other
32
57
Age
Less than 20
14
24
20-34
36
64
35-39
5
9
Greater than 40
1
12
Prenatal Care
None
2
3
Inadequate
6
11
Unknown
16
29
Adequate*
24
43
Excluded (abortion or ectopic)
8
14
’Initial evaluation prior to 20 weeks' gestation with regular fol-
lowup for at least five visits.
Table 3. Parity and duration
of pregnancy.
Parity
Number
Percent
0
13
23
1-3
25
45
4-6
4
7
Unknown
14
25
Gestational Age
Less than 20 weeks
13
23
20-28 weeks
12
21
28-40 weeks
15
27
Postpartum
10
18
Postabortal
6
11
DISCUSSION
The death of a pregnant woman is perceived as
a singular tragedy by medicine and society. The
relative infrequency of its occurrence can exaggerate
the inaccurate and unrealistic belief that the death
of such a patient no longer occurs in today’s practice
of medicine.
The analysis of maternal deaths has important
public health and preventive health implications. Of
separate and equal importance is the examination
of a maternal death by the health professionals most
closely associated with the care of the patient. A
constructive review with factual and objective infor-
mation can replace the hearsay and conjecture that
frequently accompany this event. Such a review
provides a forum for valid data collection, formal
Table 4. Classification and preventability.
Nonmaternal 16
Maternal 40
Indirect 22
Nonpreventable 17
Preventable 5
Direct 18
Nonpreventable 9
Preventable 9
Physician Factor 11
Patient Factor 3*
*ln one death, physician and patient shared preventability.
discussion of medical care, and purposeful exami-
nation of alternative approaches. The result is a
relevant, factual, and objective documented record.
The initiation of a retrospective analysis of a pa-
tient’s death is a responsibility of the leadership of
the hospital’s department of obstetrics and
gynecology. The mechanism for doing so lends itself
to the following generic description.
A portion of a regularly scheduled departmental
meeting is set aside for a clinical conference. Mem-
bers of the department personally caring for the pa-
tient and other health professionals who provided
care are invited. Furthermore, because the review
may result in a stimulus for change, those individ-
uals who are responsible for supervising care in the
involved disciplines are invited to attend, so mem-
bers of the departments of nursing, clinical labora-
tories, social services, anesthesiology, pediatrics,
medicine, and surgery will be at the meeting. A
written protocol, prepared by a delegated member
of the department, abstracts facts of the case in a
succinct, accurate, and objective manner. The focus
is directed at material pertinent to the outcome with
specific attention directed to the contributions by
the medical practitioners, to the health care system,
and to the patient. The mission is to identify causal
versus casual linkages. This is prepared in draft form
by the obstetrician for review, editing, and concur-
rence by the physicians directly involved with the
patient. The final document need not identify the
patient. This protocol is distributed to the attendees
at the time of the meeting. The chair of the depart-
ment or a designee is the moderator of the meeting.
The sequence begins with the presentation of the
written case protocol followed by the audience ask-
ing questions for clarification. These questions fre-
quently highlight areas of appropriate care, dis-
agreement about care, and deficiencies in the ability
VOL. 87— NUMBER 12 DECEMBER 1990
997
Table 5. Causes of death.
I. Nonmaternal 16
Drug Overdose 6
Auto Accident 6
Homicide 3
Suicide 1
II. Maternal 22
A. Indirect 17
1. Nonpreventable 17
AIDS 6
Lung Conditions 3
Cardiovascular Disease 5
Other 3
2. Preventable 5
Adult Respiratory Distress Syndrome 3
Systemic Lupus 1
Aortic Stenosis 1
B. Direct 18
1. Nonpreventable 9
Unexplained 3
Pulmonary Embolus 2
Preeclampsia 1
Eclampsia 1
Acute Hepatic Necrosis 1
Ectopic Pregnancy 1
2. Preventable 9
Adult Respiratory Distress Syndrome 2
Anesthesia 3
Preeclampsia 1
Splenic Artery Aneurysm 1
Postpartum Hemorrhage 1
Sepsis 1
to provide care. The moderator’s task is to maintain
an atmosphere of objectivity, impartiality, and con-
structive criticism. Control of the discussion is par-
ticularly helped by the avoidance of cross conversa-
tions and interruptive remarks by the audience. It
is appropriate for the moderator to make inter-
pretations after some individuals’ comments and to
question other comments in order to maintain direc-
tion and purpose.
When a cause of death can be identified, an ap-
propriate, education-oriented discussion should
ensue. When possible, a local recognized authority
may be invited, but a member of the department
usually can be found to present the information in
an effective manner. The patient’s death frequently
serves to illustrate specific features of the known
facts about the disease process. This can result in
enhanced learning.
A final responsibility of the moderator is to
provide an oral and written summary of the meeting.
The oral summary is most helpful when it
emphasizes opportunities for improvement, change,
and/or modifications that may help to prevent recur-
rence. The written summary lists the highlights of
the patient’s course, the contents of the discussion
in general terms, and any plans that will be pursued.
It is not necessary or appropriate to make comments
that assign value judgments. These minutes are kept
in the department’s files with a copy to the hospital’s
risk manager.
It is naive and inappropriate for any physician to
ignore the medicolegal climate of today’s practice of
medicine. A maternal death can stimulate concerns
of professional liability. These concerns are destruc-
tive when they interfer with retrospective evaluation
of actions and events, and thus, stifle professional
learning. Physicians need to understand their legal ^
responsibilities and how to diminish the risk of law-
suits. Hospital risk management personnel can serve ■'
as colleagues in a review process; their control and
dictation of the process is not expected, necessary, -
or appropriate.
SUMMARY
There was an abrupt increase in the number of
maternal deaths in New Jersey in 1988. The state
average over the past five years is 26 maternal
deaths. This increase is due to increased surveillance
on the part of the New Jersey State Department of i
Health and the use of the newer death certificate '
requiring the death of a pregnant woman to be [
noted. Local departmental clinical conferences con-
cerning maternal mortality lend themselves to a for-
mat that is professional and pertinent, and facili- a
tates learning. We urge their consistent implementa- i1 2 3
tion by local departments. ■
REFERENCES
1. Steffen GE: Quality medical care, a definition.
JAMA 260:56-61, 1988.
2. Donabedian A: The quality of care. How can it be
assessed? JAMA 26:1743-1748, 1988.
3. Practive Management: PRECIS IV. Amer Coll Ob-
stet Gynecol Washington DC, 1989.
4. Quality assurance, monitoring, and evaluation in ob-
stetrics and gynecology. Obstet Gynecol/Report 1:244-248,
1989.
5. Koonin LM, Atrash HE, Rochat RW, Smith JC: Ma-
ternal mortality surveillance, United States, 1980-1985.
MMWR 37:19-29, 1988.
•i.
998
NEW JERSEY MEDICINE
CASE REPORT
Crack-Induced
Enteric Ischemia
DAVID C. HON, MD
LESLIE J. SALLOUM, MD
HOWARD W. HARDY, III, MD
JAMES E. BARONE, MD
Rare instances of intestinal ischemia subsequent to cocaine use have been
reported. Crack abuse, linked to gastroduodenal ulcer perforation, has not
been associated with mesenteric infarction until this case report.
Small bowel ischemia can result from cocaine
abuse.1'3 This complication can occur
whether cocaine is ingested or inhaled nasal-
ly. With the introduction of freebase cocaine or
“crack,” gastrointestinal ischemia manifesting as
acute gastropyloric ulceration has been reported.4
We present a case of small bowel ischemia secondary
to crack abuse.
A 37-year-old black female presented to the
From the Department of Surgery, St. Francis Medical
Center, Trenton, where Dr. Hon is a resident in surgery,
Dr. Salloum is the chief resident in surgery, Dr. Hardy
is attending in surgery, and Dr. Barone is director of
surgery. The paper was submitted in April 1990 and
accepted in July 1990. Requests for reprints may be
addressed to Dr. Barone, St. Francis Medical Center, 601
Hamilton Avenue, Trenton, NJ 08629.
emergency department of St. Francis Medical
Center, Trenton, with a five-day history of nausea,
vomiting, and abdominal pain. The pain was de-
scribed as constant and sharp in nature, and lo-
calized primarily in the periumbilical and
suprapubic areas. The patient was anorectic and
obstipated without fever, chills, or melena.
The patient had a history of alcohol abuse. She
had used intravenous cocaine and heroin about 14
years earlier. However, she had started using crack
occasionally in the preceding two months. The last
use was one day prior to her present symptoms.
The patient was uncomfortable and dehydrated.
Vital signs were normal. Skin and mucous mem-
branes appeared dry. Lungs were clear to aus-
cultation. Abdomen was distended with hypoactive
VOL. 87— NUMBER 12 DECEMBER 1990
1001
CASE REPORT
bowel sounds, tenderness, rebound, and guarding in
all four quadrants. The right lower quadrant was
slightly more tender than the left quadrant. No stool
was present in the rectum. White blood cell count
was 8700 mm1 with 57% neutrophils, 11% bands, and
28% lymphocytes. Hemoglobin was 12.6 gm/dL and
hematocrit was 38.1%. Serum amylase was normal
with sodium 134 meq/L; potassium was 3.5 meq/L;
chloride was 92 meq/L; carbon dioxide was 32
meq/L; urea nitrogen was 45 mg/dL; and creatinine
was 1.3 mg/dL. Abdominal x-rays showed small
bowel distension with a small amount of air in the
colon.
We made a diagnosis of small bowel obstruction
secondary to perforated appendix or adhesions. The
patient underwent exploratory laparotomy. Approx-
imately 50 ml of serosanguinous fluid was found in
the abdominal cavity. The distal ileum appeared
hemorrhagic with areas of gangrene and multiple
strictures. The involved bowel was resected. The
patient did well postoperatively except for a wound
infection that was treated and resolved.
The pathology report showed 50.5 cm of distal
ileum with multiple areas of segmental constriction.
The mucosa was hemorrhagic with three segments
of hemorrhagic infarction, superficial areas of ul-
ceration, and marked venous congestion of the
mesentery without mesenteric vein thrombosis. The
lumen of the vermiform appendix was patent
without evidence of inflammation.
DISCUSSION
The first case of intestinal ischemia caused by
cocaine ingestion was reported in 1985 by Nalban-
dian. ' Intestinal ischemia caused by cocaine sniffing
subsequently was reported.2 More recently, gastro-
pyloric ulcers also have been reported after crack
abuse.4 This case illustrates that a short period of
crack abuse can lead to intestinal ischemia. Crack
has been noted to have a rapid and intense effect
upon the central nervous, cardiovascular, and
gastrointestinal systems.5
The capacity of cocaine to cause profound
vasoconstriction is exemplified by the occurrence of
nasal septal perforation with intranasal use of co-
caine. At the cellular level, cocaine causes blockade
of the re-uptake of norepinephrine at adrenergic
nerve endings, potentiating the effects of sym-
pathetic nerve stimulation and resulting in
vasoconstriction of regional vessels. This major
pharmacologic effect of cocaine leads to ischemia of
the heart6 and gastrointestinal system.2'4 In the
cardiovascular system, myocardial ischemia results
from vasoconstriction of the coronary arteries and a
decrease in coronary blood flow.67 In the stomach,
localized ischemia in the pyloric region may account
for the ulceration reported by Abramson.4 In the
small bowel, cocaine probably affects the superior
mesenteric artery causing a nonocclusive mesenteric
ischemia. Other causes of nonocclusive mesenteric
ischema include congestive heart failure, myocar-
dial infarction, cardiac arrhythmias, digitalis ther-
apy, and factors causing mesenteric vasoconstriction
such as hypovolemia, hemoconcentration, septic
shock, and use of vasopressors.89 With the increase
in crack abuse, physicians must consider the possi-
bility of gastrointestinal ischemia in addicts pre-
senting with abdominal pain. As a consequence, the
patient may present with ileus or small bowel ob-
struction. A high index of suspicion is important for
appropriate therapy of this condition. In the late
stage of the disease, bowel resection with anas-
tomosis is the treatment of choice. The use of fluo-
rescein or ultrasound intraoperatively may help de-
termine the extent of the resection.3
With earlier detection, cocaine-induced mesen-
teric ischemia might be treated conservatively. A
case of nonocclusive mesenteric vascular insufficien-
cy secondary to heart failure was successfully treated
with tolazoline injected through the same superior
mesenteric arterial catheter used to establish the
diagnosis as reported by Habboushe. Drugs such as
papaverine, glucagon, phenoxybenzamine, and iso-
proterenol can be possible therapeutic agents.9
Prostacyclin, a potent, short-acting vasodilator, also
could be used. ■
REFERENCES
1. Creglar LL, Mark H: Special report — medical com-
plications of cocaine abuse. N Engl J Med 315:1495-1499,
1986.
2. Mizrahi S, Laor D, Stamler B: Intestinal ischemia
induced by cocaine abuse. Arch Surg 123:394, 1988.
3. Nalbandian H, Sheth N, Dietrich R, et al.: Intestinal
ischemia caused by cocaine ingestion: Report of two cases.
Surgery 97:374-376, 1985.
4. Abramson DL, Krai IG, Gertler -JP, et al.:
Gastropyloric ulcers related to crack. JAMA 262:617-618,
1989.
5. Washton AM, Gold MS, Pottash AC: Crack: Early
report of a new drug epidemic. Post Grad Med 80:52-58,
1986.
6. Smith HWB III, Liberman HA, Brody SL, et al.:
Acute myocardial infarction temporally related to cocaine
use. Clinical, angiographic, and pathophysiologic observa-
tions. Ann Intern Med 107:13-18, 1987.
7. Lange RA, Cigarroa RG, Yancy CW et al.: Cocaine-
induced coronary artery vasoconstriction. N Engl J Med
321:1557-1562, 1989.
8. Berger RL, Byrne JJ: Intestinal gangrene associated
with heart disease. Surg Gynecol Obstet 112:529-533, 1961.
9. Habboushe F, Wallace HW, Nusbaum M, et al.:
Nonocclusive mesenteric vascular insufficiency. Ann Surg
180:819, 1974.
1002
NEW JERSEY MEDICINE
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Noninvasive Diagnosis of
Deep Vein
Thrombosis
EDWARD G. MOSS, MD
JAMES ALEXANDER, MD
Deep vein thrombosis is a serious medical problem that may lead to
pulmonary embolus. The authors discuss the noninvasive diagnosis of deep
vein thrombosis using venous occlusion plethysmography and ultrasonic
duplex scanning.
Deep vein thrombosis (DVT) is a major cause
of morbidity and mortality in hospitalized
patients. The incidence of DVT in patients
over 40 undergoing major surgical procedures ap-
proaches 50 percent. The most feared complication
of DVT is pulmonary embolus (PE). As many as 10
percent of patients with DVT may develop PE. Over
150,000 fatal pulmonary emboli occur in the United
States each year. The clinical diagnosis of DVT is
50 percent accurate. Therefore, objective tests are
needed to make the diagnosis.
I125 fibrinogen scans, used for the detection of DVT
of the lower extremity, can detect active thrombus
in calf and popliteal veins. While it is a very
Dr. Moss is attending, Department of Diagnostic Radi-
ology and Nuclear Medicine, Cooper Hospital/University
Medical Center, and clinical associate professor of radi-
ology, UMDNJ-Robert Wood Johnson Medical School.
Dr. Alexander is assistant, Department of Surgery,
Cooper Hospital/University Medical Center, and assis-
tant professor of surgery, UMDNJ-Robert Wood Johnson
Medical School. The paper was submitted in May 1990
and accepted in July 1990. Requests for reprints may be
addressed to Dr. Moss, Cooper Hospital/University
Medical Center, One Cooper Plaza, Camden, NJ 08103.
sensitive test for active clot, an I125 fibrinogen scan
has several major disadvantages: it is very
nonspecific; ionizing radiation exposure and the
necessity to block thyroid uptake has to be con-
sidered; completion usually requires several days;
and availability of the isotope is quite limited.
Magnetic resonance imaging (MRI) as an imaging
modality for DVT of the lower extremity is not a
proved clinical method, although it is undergoing
clinical research trials. Currently, the diagnostic
modalities of choice at Cooper Hospital are venous
occlusion plethysmography (VOP) and ultrasonic
duplex scanning.
VOP is a technique that takes advantage of the
hemodynamic changes that occur in the leg as a
consequence of DVT. A blood pressure cuff is ap-
plied to the thigh and inflated to a pressure of ap-
proximately 60 mmHg, enough to obstruct venous
return but not to impede arterial inflow. A second
cuff is used to measure changes in volume of the calf.
The calf volume increases as the veins fill and dis-
tend with blood. After maximal filling has been
achieved, the thigh tourniquet is abruptly released
and a reduction in volume of the calf is measured
as the venous blood flows out of the calf and back
VOL. 87— NUMBER 12 DECEMBER 1990
1005
OUTFLOW II sec. | = 100%
CAPACITANCE
= 21
Figure 2. VOP trace demonstrating reduced venous ca-
Figure 3. VOP trace demonstrating reduced venous
outflow.
toward the heart. This provides two measurements
of venous hemodynamics, the venous filling or ca-
pacitance and the venous outflow, measured by con-
vention for the first second after tourniquet release.
The test is performed supine: the leg veins are
nearly empty at rest and normally considerable fill-
ing can be demonstrated. The capacitance should be
approximately equal bilaterally. The outflow at one
second normally is about 100 percent and, again,
should be symmetrical (Figure 1). In the presence
of a proximal occluding venous thrombus, the veins
in the calf may be partially distended with blood
prior to application of the thigh tourniquet so venous
capacitance may be reduced (Figure 2). Also, release
of the tourniquet may result in sluggish venous
outflow because of the obstructing proximal clot
(Figure 3). An asymmetry in venous capacitance
between the two legs of greater than 20 percent is
associated with the presence of DVT. Also, a reduc-
tion in venous outflow at one second to 50 percent
or less of baseline is diagnostic of DVT. With these
criteria, a sensitivity of 80 percent and a specificity
of 87 percent has been achieved for the diagnosis of
DVT with an overall accuracy of 81 percent.1 Simi-
larly, when looking for residual thrombi in patients
sustaining clinically significant PE, this technique
has demonstrated a sensitivity of 100 percent and a
specificity of 92 percent for an overall accuracy of
97 percent.2
Despite the usefulness of the plethysmographic
technique, there are several pitfalls. The technique
Figure 4A. A = common femoral artery; and V = com-
mon femoral vein.
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Figure 4B. Vein obliterated after compression
cannot distinguish intrinsic obstruction caused by
thrombus from extrinsic compression by tumor,
hematoma, or abscess. Thrombi that do not occlude
veins may not produce the same hemodynamic ef-
fects and, therefore, may be missed by a test that P
relies on alterations in the functional hemo-
dynamics.
Similarly, patients that have had previous DVT
may have developed abundant collateral veins that
similarly can mask the hemodynamic abnormality
in the event of a recurrent ipsilateral DVT. Conse-
quently, although VOP is diagnostically useful, the
clinician may find it reassuring to have the
hemodynamic data confirmed with anatomic vis-
ualization of the underlying pathology. For this
reason, we also image the deep veins directly.
Contrast venography (CV) has long been con-
sidered the “gold standard” for the diagnosis of
acute DVT. However, improved technology has
enabled ultrasonic duplex scanning to approach
NEW JERSEY MEDICINE
1006
Figure 5A. A = common femoral artery; and B = com-
mon femoral vein.
diagnostic accuracy of CV. Since CV is invasive,
involves radiation exposure, and uses iodinated con-
trast material, there are contraindications and com-
plications. Technical problems with vein cannula-
tion, local extravasation of dye in the foot, and in-
complete filling of deep veins with resulting dif-
ficulties in interpretation can occur in up to 10 per-
cent of CVs. Contrast-induced phlebitis as a conse-
quence of CV also can occur. Therefore, duplex
scans, that are noninvasive and involve no radiation
or dye, may be considered as an alternative for the
diagnosis of DVT. Duplex scanning implies dual
ultrasonic modalities: real-time (B-mode) imaging
and Doppler flow.
The normal ultrasound appearance of a deep vein
is that of an echo-free lumen with smooth internal
surfaces. An important characteristic of a normal
vein is compressibility. Normal veins are fully com-
pressible by gentle external pressure from the hand-
held transducer (Figures 4A and 4B). When the
lumen of a vein contains thrombus, it will not com-
press (Figures 5A and 5B). This is best evaluated in
the transverse plane. Thrombus may occasionally be
directly visualized in the sagittal plane although this
may be a more difficult observation.1 2 3
Using the Doppler mode, normal spontaneous flow
is detected in large and midsize veins at rest.
Smaller calf veins require augmentation by distal
compression of the leg to visualize flow. Midsize and
large veins also show an augmented response to
1. McLandless ME, Young JR, Swift CL: Noninvasive
diagnosis of clinically suspected deep venous thrombosis.
Cleve Clin Q 52:555-560, 1985.
2. Huisman MV, Buller HR, Ten Cate JW, Vreeken J:
Serial impedance plethysmography. N Engl J Med
314:823-828, 1986.
Figure 5B. Common femoral vein filled with thrombus,
not compressible.
squeeze. The lack of augmented flow in deep veins
of the leg indicates obstruction. Also, in larger veins,
where respiratory variation is a normal finding, its
absence indicates obstruction.
During a duplex examination, the anterior and
posterior tibial veins, and popliteal, superficial
femoral, and common femoral veins are examined.
The sensitivity of the examination for DVT is 91
percent and the specificity is 99 percent. It should
be noted that the sensitivity is much less for isolated
calf vein thrombi, but since these have a low risk
of PE this may not be an important shortcoming.
These considerations have led us to the following
algorithm. We perform bilateral VOP and duplex
scan of the symptomatic leg or the one with the
abnormal VOP study. If DVT is documented, the
diagnosis is established and no further workup is
needed. If DVT is not found and clinical suspicion
is high, further workup with CV, lung scan, or
pulmonary angiogram may be appropriate. If the
finding of VOP and duplex scan are discordant, i.e.
VOP is positive for DVT but duplex scan fails to
demonstrate thrombus, CV is performed to clarify
the diagnosis.
We have achieved a high degree of accuracy in the
diagnosis of DVT with this approach. CV remains
a valuable tool in selected patients, but most pa-
tients at Cooper Hospital can be satisfactorily evalu-
ated without the risk or discomfort thanks to the
development of the newer noninvasive modalities. ■
3. Raymond HW, Zwiebel WJ, Harnsberger HR:
Duplex sonography of the venous system. Sem Ultra-
sound, CT, MR 9:269-319, 1988.
4. Lensing AWA, Prandoni P, Brandies D, et ah: Detec-
tion of deep venous thrombosis by real-time B-mode ultra-
sonography. N Engl J Med 320:342-345, 1989.
VOL. 87— NUMBER 12 DECEMBER 1990
1007
ilvates*
50 mg
“Recent research
has delineated
early, more subtle
changes in lung and
immune functions. These
alterations directly
predispose smokers to
respiratory tract infection.”
Am Fam Phys 1987;36:133-140
racior
Established therapy
for today’s patients
For respiratory tract infections due to
susceptible strains of indicated organisms
'
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[
Brief Summary.
Consult the package literature for prescribing information.
Indication: Lower respiratory inlections. Including
pneumonia, caused by Streptococcus pneumoniae,
Haemophilus influenzae, and Streptococcus pyogenes
(group A 0-bemolytic streptococci).
Contraindication: Known allergy to cephalosporins.
Warnings: CECLOR SHOULD BE ADMINISTERED
CAUTIOUSLY TO PENICILLIN-SENSITIVE PATIENTS.
PENICILLINS AND CEPHALOSPORINS SHOW PARTIAL
CROSS-ALLERGENICITY. POSSIBLE REACTIONS
INCLUDE ANAPHYLAXIS.
Administer cautiously to allergic patients.
Pseudomembranous colitis has been reported with
virtually all broad-spectrum antibiotics. It must be con-
sidered in differential diagnosis of antibiotic-associated
diarrhea. Colon flora is altered by broad-spectrum
antibiotic treatment, possibly resulting in antibiotic-
associated colitis.
Precautions:
• Discontinue Ceclor in the event ot allergic reactions to it.
• Prolonged use may result in overgrowth of non-
susceptible organisms.
• Positive direct Coombs’ tests have been reported
during treatment with cephalosporins.
• Ceclor should be administered with caution in the
presence of markedly impaired renal function. Although
dosage adjustments in moderate to severe renal
impairment are usually not required, careful clinical
observation and laboratory studies should be made
• Broad-spectrum antibiotics should be prescribed with
caution in individuals with a history of gastrointestinal
disease, particularly colitis.
• Safety and effectiveness have not been determined in
pregnancy, lactation, and infants less than one month
old. Ceclor penetrates mother's milk. Exercise caution
In prescribing for these patients.
Adverse Reactions: (percentage of patients)
Therapy-related adverse reactions are uncommon.
Those reported include:
• Hypersensitivity reactions have been reported in about
1.5% of patients and include morbilliform eruptions
(1 in 100). Pruritus, urticaria, and positive Coombs’
tests each occur in less than 1 in 200 patients. Cases
of serum-slckness-like reactions have been reported
with the use of Ceclor. These are characterized by
findings of erythema multiforme, rashes, and other skin
manifestations accompanied by arthritis/arthralgia, with
or without fever, and differ from classic serum sickness
in that there is infrequently associated lymphadenopathy
and proteinuria, no circulating immune complexes, and
no evidence to date of sequelae of the reaction. While
further investigation is ongoing, serum-sickness-llke
reactions appear to be due to hypersensitivity and more
often occur during or following a second (or subsequent)
course of therapy with Ceclor. Such reactions have been
reported more frequently in children than in adults with
an overall occurrence ranging from 1 in 200 (0.5%) in
one focused trial to 2 in 8,346 (0.024%) in overall
clinical trials (with an incidence in children in clinical
trials of 0.055%) to 1 in 38,000 (0.003%) in spon-
taneous event reports. Signs and symptoms usually
occur a few days after initiation of therapy and subside
within a few days after cessation of therapy; occasion-
ally these reactions have resulted in hospitalization,
usually of short duration (median hospitalization = two
to three days, based on postmarketing surveillance
studies). In those requiring hospitalization, the symp-
toms have ranged from mild to severe at the time of
admission with more of the severe reactions occurring
in children. Antihistamines and glucocorticoids appear
to enhance resolution of the signs and symptoms. No
serious sequelae have been reported.
• Stevens-Johnson syndrome, toxic epidermal necrolysis,
and anaphylaxis have been reported rarely. Anaphylaxis
may he more common in patients with a history of
penicillin allergy
• Gastrointestinal (mostly diarrhea): 2.5%
• Symptoms of pseudomembranous colitis may appear
either during or after antibiotic treatment.
• As with some penicillins and some other cephalo-
sporins. transient hepatitis and cholestatic jaundice
have been reported rarely.
• Rarely, reversible hyperactivity, nervousness, insomnia,
confusion, hypertonia, dizziness, and somnolence have
been reported.
• Other: eosinophilia, 2%; genital pruritus or vaginitis,
less than 1% and, rarely, thrombocytopenia and reversible
interstitial nephritis.
Abnormalities in laboratory results of uncertain etiology.
• Slight elevations in hepatic enzymes.
•Transient lymphocytosis, leukopenia, and, rarely,
hemolytic anemia and reversible neutropenia.
• Rare reports of increased prothrombin time with or
without clinical bleeding in patients receiving Ceclor
and Coumadin concomitantly.
• Abnormal urinalysis; elevations in BUN or serum
creatinine.
• Positive direct Coombs’ test.
■ False-positive tests for urinary glucose with Benedict’s
or Fehling’s solution and Cllnitest- tablets but not with
Tes-Tape* (glucose enzymatic test strip, Lilly).
PA 8791 AMP (021490LRI1
Additional information available to the profession
on request from Ell Lilly and Company. Indianapolis,
Indiana 46285.
Eli Lilly Industries, Inc
Carolina, Puerto Rico 00630
A Subsidiary of Eli Lilly and Company
Indianapolis, Indiana 46285
CR-0525-8-049333 © 1990, EU URY AND COMPANY
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1008
NEW JERSEY MEDICINE
1
Nicholas A. Bertha, MD
NANCY M. PROPSNER
Nicholas Aladar Bertha, MD, has been an
asset to the Dover area for over 50 years.
Dr. Bertha opened Dover General Hospital
and Medical Center’s first cancer clinic in 1946, and
was in charge of the clinic until 1960. Recently, a
new cancer therapy and education center at Dover
General Hospital and Medical Center has been
named in his honor. “Naming our new cancer center
after Dr. Bertha reflects our admiration of his self-
less dedication to his patients and our appreciation
of his exceptional contributions to the history and
growth of Dover General Hospital and Medical Cen-
ter,” explained hospital president, Wayne Schiffner.
The highlight of the $2.5 million Dr. Nicholas A.
Bertha Regional Cancer Center is a dual energy
megavolt linear accelerator, providing precision and
accuracy while minimizing cancer treatment side
effects.
Born and raised in Wharton, Dr. Bertha helped
to establish the borough’s first aid squad and the
practical nursing course at Morris Hills High School.
He also served on the board of directors at Dover
General Hospital and Medical Center. In 1953, Dr.
Bertha helped to found St. Clare’s Riverside Medi-
cal Center, Denville, serving as the director of sur-
gery until 1964 and as president of the medical staff
for two years. He also served on Wharton’s Fire De-
partment and Board of Health.
Recently, the town of Wharton honored Dr.
Bertha with the Dover-West Morris Annual Com-
munity Service Award. The monument was pre-
sented to Dr. Bertha by the Chamber of Commerce
for his long-time dedication to Morris County’s
health care system and to his community.
Following his graduation from Wharton High
School, Dr. Bertha received his bachelor of science
degree from New York University in 1928, and his
medical degree from New York University-Bellevue
Hospital Medical School, New York City, in 1932.
Dr. Bertha served a residency in gynecology and
obstetrics at Lying-In Hospital and a surgical resi-
dency at Bellevue Hospital, both in New York City.
Dr. Bertha then pursued a four-year postgraduate
course in surgery at New York University School of
Ms. Propsner is the editorial assistant for NEW JERSEY
MEDICINE.
Medicine. Dr. Bertha opened his private general sur-
gery and gynecology practice in Dover in 1937.
Dr. Bertha served as president of the Medical So-
ciety of New Jersey in 1969, of the Morris County
Medical Society, and of the Society of Surgeons of
New Jersey. Dr. Bertha was a founding member of
Dr. Nicholas Bertha
the New Jersey Obstetrical and Gynecological So-
ciety, and is a member of the American Medical
Association and our Morris County component. In
addition, Dr. Bertha served as chairman for two
years for the Medical Society of New Jersey Board
of Trustees. He is a fellow of the International Col-
lege of Surgeons, and of the American College of
Surgeons, appointed to the executive council of the
New Jersey chapter of the American College of Sur-
geons.
Serving in World War II, as an Army major from
1942 to 1945, Dr. Bertha commanded the 662nd
Medical Clearing Company and helped to establish
the field surgical hospitals. He served in these hospi-
tals in France and Germany as a battlefield surgeon.
Dr. Bertha was honored with six campaign battle
stars, with the Bronze Star, and with a distinguished
unit commander citation.
Retired since 1987, Dr. Bertha, who resides in
Lake Hopatcong with his wife, Phyllis, has two sons,
Nicholas J. and John Allen, six grandchildren, and
one great grandchild.
VOL. 87— NUMBER 12 DECEMBER 1990
1009
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NEW JERSEY MEDICINE
ad
1010
Antisense DNA-
Analogs
Inhibition of Human Immunodeficiency Virus
YON EBRIGHT, PhD LAWRENCE FRENKEL, MD
KAREL RASKA, Jr, MD JONGLIN TSAO
SUNANDA GAUR, MD STANLEY STEIN, PhD
Considering the complexity of life processes
and the precision of the development of an
organism, genetic information must be
under fine control. The challenge is to develop drugs
to imitate natural processes and influence genes as-
sociated with specific diseases.
Genetic regulation was thought to be exclusively
under the control of proteins, e.g. inducers, re-
pressors, transactivators. Inouye and coworkers were
among the first investigators to report that RNA
transcripts, produced by specific regulatory genes,
can act as regulatory factors.1 These molecules have
been named antisense RNA, since they are com-
plementary to the “sense” RNA strand, such as the
mRNA that codes for a protein. A gene that codes
for an antisense RNA is termed an antisense gene.
Experimentation already has demonstrated the
capability of mimicking this control mechanism by
using DNA constructs that code for antisense RNA.
In an early example, a plasmid-containing antisense
construct to /J-galactosidase mRNA was shown to
inhibit biosynthesis of this protein by 98 percent.2
Similarly, plasmids carrying antisense genes for the
coat protein, the replicase, and the maturation pro-
tein of coliphage SP were constructed; E. coli trans-
fectants became resistant to this phage.34 Antisense
constructs have been introduced into eukaryotic
cells and this research attracts attention.512
The authors are affiliated with UMDNJ-Robert Wood
Johnson Medical School. The manuscript was submitted
in June 1990 and accepted in July 1990. Requests for
reprints may be addressed to Dr. Stein, Center for Ad-
vanced Biotechnology and Medicine, 679 Hoes Lane,
Piscataway, NJ 08854-5635.
Multiple mechanisms of inhibition are possible. In
one example, the antisense RNA hybridizes to and
thereby blocks a primer RNA for plasmid replica-
tion.1 The inhibition of an mRNA by an antisense
RNA can be through a process called “translation
arrest,” in which translation initiation and/or
elongation is sterically prevented (Figure 1).
SYNTHETIC ANTISENSE MOLECULES
The use of a biological vector, such as an at-
tenuated or disabled virus, for administering anti-
sense DNA to a human or an animal has certain
attributes. It overcomes the problems associated
with getting such a “drug” into target cells in an
active form. That is, it utilizes the cellular uptake
and genetic regulatory elements inherent to that
viral vector. Furthermore, replication of the virus
would assure a continual supply of antisense RNA.
Production of such biological drugs are within the
capabilities of current recombinant DNA tech-
nology, but the biohazard risks will have to be evalu-
ated carefully before such microorganisms, if con-
structed, could be used therapeutically.
The alternative is to use chemically synthetic
antisense molecules, such as short, single-stranded
DNA. In this case, the DNA would not act to code
for an antisense RNA, but would interact directly
with its complementary target. An early experiment
demonstrated the ability of a 13-residue synthetic
oligodeoxyribonucleotide, i.e. a 13-mer, to inhibit
the cell-free translation of Rous sarcoma viral
RNA.13 With the advent of automated DNA syn-
thesizers, short DNA-oligonucleotides have been
used in many studies to inhibit cellular processes,
NEW JERSEY MEDICINE
1011
even in whole cells. For example, it was possible to
“reverse” the phenotypic transformed state of
human promyelocytic leukemia (HL-60) cells by in-
hibiting the myc proto-oncogene.14 In this study, it
"active"
antisense "passive"
oligonucleotide antisense
Figure 1. Representation of inhibitory mechanisms of antisense
oligomers. An antisense RNA, DNA, or DNA-analog can "pas-
sively” inhibit translation of an mRNA into protein by sterically
preventing ribosomal initiation or elongation. The “active” ver-
sion of an antisense oligomer would have a pendant group
capable of permanently disabling the target mRNA, such as by
scission or by crosslinking. The antisense strand also might
activate RNase H digestion of the mRNA target in a catalytic
manner.
was shown that a 15-mer, complementary to the
initiation codon region of c-myc mRNA, con-
comitantly inhibited c-myc protein expression and
cell proliferation in culture. In another example,
DNA-oligonucleotides ranging in length from 12 to
26 residues were shown to be capable of substantially
inhibiting HIV-1, the causative virus of AIDS, in
infected cultured human lymphocytes.15
When the antisense strand is DNA, another mech-
anism of inhibition of target RNA is possible.16 This
is through the action of RNase H, an enzyme known
to hydrolyze the RNA partner of an RNA/DNA
duplex. This should constitute a catalytic mechan-
ism, since the DNA strand is released after
hydrolysis of the RNA strand and it then is able to
bind and cause degradation of other RNA strands.
Other approaches for inhibiting DNA or RNA
targets have been devised. An active moiety on the
DNA-oligonucleotide could be used to cause target
strand destruction (Figure 1). One notable example
is the hydroxyl free-radical generating system em-
ploying an iron-chelate complex.17
figi
¥
' oeg
11C
BACKBONE-MODIFIED OLIGONUCLEOTIDES
FiS
There are potential technical obstacles to the use tie
of synthetic DNA-oligonucleotides as drugs. First, j«
Table. Inhibition of HIV with antisense DNA-analogs.
20-25
Cone.
% Inhibition
Compound/Type
Sequence (5'— >3')
^g/ml
Syncytia
p24
1. Control DNA
ACACCCAATTCTGAAAATGG
4
33
44
20
33
39
100
65
44
2. Methylphosphonate
ACACCCAATTCTGAAAATGG
4
60
62
20
98
100
100
100
100
3. Methylphosphonate
ACACCCAATTCTGAAAATGG
4
39
0
20
50
50
100
85
78
4. Phosphorothioate
ACACCCAATTCTGAAAATGG
4
38
63
20
86
91
100
100
100
5. Phosphorothioate
CGAGATAATGTTCACACAAC
4
0
0
20
89
93
100
100
100
6. Phosphormorpholidate
ACACCCAATTCTGAAAATGG
4
59
57
20
91
86
100
(toxic)
The sequence is antisense to a tat splice acceptor site, except for compound 5 that is a nonspecific sequence.
Nucleoside 3'-modified linkages are underlined (i.e. compound 2 has one phosphodiester bond).
Based on the molecular weights of these compounds, 100 ^g/ml is equivalent to about 15 //M.
HIV-1 was added to H-9 or MOLT-3 cells at a virus particle to cell multiplicity of about 1000. Oligonucleotides were added at the
same time and bioassays were done after 96 hours.
NEW JERSEY MEDICINE
1012
o
o
o
o
/ 11 \
/ H \
/ H \
/ II
"h
0
1
a -
O
4-^
0
1
CL -
o
0
1
Q. -
1
o
i
0
1
Q. -
1
O
O"
ch3
1
S -
phosphodiester
methylphosphonate
phosphorothioate
morpholidate
(DNA)
Figure 2. Structures of internucleoside linkages in backbone-modified DNA. These examples represent compounds that have been
synthesized and tested for anti-HIV activity, as listed in the Table. The phosphorothioate analog is similar to DNA in that it has a
negative charge. The three analogs shown can exist in two stereoisomeric forms, whereas the two oxygen atoms in DNA, not in
phosphodiester linkage, are equivalent resonance structures.
HIV-1 DNA
D
□
LTR
rrn
gag
VIF
, LT
net — —
1 LI I
TAR
pol
H
env
— nz _
rev
tat
Q
\
tat
Figure 3. Schematic representation of the genetic map of HIV proviral DNA. The positions of the various genes and regulatory
elements are shown on the 9.7 kilobase HIV genome. The LTRs contain regulatory elements for viral gene expression and replication,
including promoter and enhancer sequences, polyadenylation signals and the TAR region, the target for the viral transactivating tat
protein. The structural genes are described in the text.
the molecules must be able to survive exposure to
degradative enzymes (nucleases) in the blood and
intracellular millieu. Second, they must be taken up
into cells, and this process has not been fully
elucidated. Although uptake occurs in cell culture,
it generally may not be applicable in vivo. To deal
with these concerns, Miller and Ts’o have pioneered
the development of nonionic, backbone-modified
DNA.18 Several different types of ionic and nonionic
internucleoside linkages (Figure 2) as well as other
types of modifications have been investigated.19
One of the most studied classes of backbone-modi-
fied oligonucleotides contains nonionic, meth-
ylphosphonate internucleoside bonds (MP-DNA).
MP-DNA has certain desirable properties. The se-
quence specificity and strength of hybridization of
MP-DNA to its complementary target is similar to
that of the usual charged DNA.20 MP-DNA is resis-
tant to nucleases and, by virtue of its noncharged
character, has enhanced uptake and access to in-
tracellular compartments.18
SYNTHESIS AND PURIFICATION OF MP-DNA
Phosphonamidite monomers are commercially
available for the synthesis of MP-DNA on auto-
mated instruments. It is possible to synthesize com-
pletely nonionic, or mixed oligomers in which some
of the internucleoside bonds are the usual phos-
phodiester linkages. The use of completely nonionic
Figure 4. HIV replication inhibition plot. A human lymphocyte
cell line permissive for HIV 1 , i.e. H9, was used for these studies.
On day 1, uninfected cells were mixed with infected cells in the
wells of a microtiter plate in 0.3 ml of culture medium with either
15-mer or 24-mer antisense MP-DNA (15 nM). At each time
point one well from each set was sampled and assayed for the
viral marker protein, p24, by immunoassay. Viral levels in wells
not containing antisense MP-DNA usually increased by 200 to
300 percent over this time interval. The 24-mer displayed essen-
tially complete inhibition, whereas the 15-mer was ineffective.
VOL. 87— NUMBER 12 DECEMBER 1990
1013
MP-DNA, however, might maximize the properties
of nuclease resistance and membrane permeability.
Accordingly, our initial experiments involved the
use of completely nonionic MP-DNA.
Purification and analysis of uncharged MP-DNA
is difficult, since elimination of charge results in
decreased solubility in physiological buffers and
greater losses due to adsorption to surfaces. Com-
monly employed procedures for handling DNA are
generally not applicable to MP-DNA. For example,
completely nonionic oligomers cannot be radio-
labelled by the enzyme, polynucleotide kinase, in a
procedure used for monitoring electrophoretic mi-
gration of DNA on gels. In fact, these oligomers do
not migrate on gels, eliminating the availability of
electrophoresis for purification and analysis
purposes. Instead, our laboratory has utilized a two-
step reversed-phase HPLC procedure, i.e. trityl-on/
trityl-off, for purification and analysis purposes;
further details on the synthesis and purification of
completely nonionic MP-DNA have been pub-
lished.21
INHIBITION OF HIV-1
HIV-1 has become one of the most studied viruses
and the entire genomic sequence of this retrovirus,
including numerous variants, is known.22 The HIV
genome has characteristics common to all retro-
viruses (Figure 3), including an LTR (long terminal
repeat) at either end of the provirus DNA and gag,
pol, and env structural genes. The LTRs contain
regulatory sequences including TAR (trans-
activating responsive element). The gag (group
specific antigens) proteins, pl7, p24, and p7/p9, par-
ticipate in the formation of the virion core. The three
proteins encoded by the pol gene are: 1) a protease
for processing the large gag-pol fusion protein into
the individual protein products: 2) a reverse tran-
scriptase for making a double-stranded DNA frag-
ment based on the sequence of the single-stranded
viral RNA; and 3) an endonuclease (integrase) for
inserting this double-stranded proviral DNA into the
host cell chromosome. The env gene encodes the
envelope protein, gpl20, that is responsible for bind-
ing to the CD4 receptor, and the transmembrane
protein, gp41, that anchors gpl20 and may be in-
volved in viral entry into the cell. In addition, the
HIV genome encodes some unique regulatory pro-
teins, tat, rev, nef, vif, vpu (or U), and vpr (or R).
Antisense therapy is among the many approaches
being explored for AIDS, and one preferred target
is the tat gene, since the tat protein has been shown
to be critical for viral replication.23 The target site
for tat protein is TAR, but the exact mechanism(s)
for transactivation has not been clarified. Several
recent publications have appeared on the inhibition
of HIV-1 using MP-DNA and other analogs that are
antisense to the tat gene, as well as to other
sites. 20-24'26 In our own cell culture studies, we have
targeted the translational initiation region of the tat
structural gene. A nonionic MP-DNA 24-mer, cover-
ing the initiation codon (AUG), as well as several
upstream bases, showed total inhibitory activity at
its solubility limit of 15 mM (Figure 4). This concen-
tration is within the range found for backbone-modi-
fied antisense oligonucleotides in other studies
(Table). Furthermore, inhibition was effective over
test periods as long as ten days (data not shown),
confirming the nuclease resistance of the MP-DNA.
A 15-mer MP-DNA, antisense to the same region,
was found not to be inhibitory when tested up to 60
/uM. Presumably, the lower complementary binding
affinity expected for a shorter oligomer was respon-
sible for this result.
The selected data in the Table from the cell cul-
ture studies of Zamecnik and coworkers, illustrate
several points. First, antisense DNA (compound 1)
is itself active in this in vitro assay, but not with
complete inhibition. Second, the use of backbone-
modified DNA (compounds 2, 4, and 5) can achieve
complete inhibition. The presence of only a few
modified linkages (compound 3) or shorter se-
quences of MP-DNA (not shown) also gave only
partial inhibition. Third, studies so far have
provided only preliminary results and many ques-
tions remain. The nature of the enhanced antiviral
activity of backbone-modified DNA, whether due to
nuclease resistance, improved cellular uptake or
some other process, has still not been determined.
The apparent activity of compound 5 (a phos-
phorothioate having a sequence unrelated to the
viral genome) suggests that other processes are oper-
ative. Toxicity toward the cellular host, most notice-
able with compound 6, a phosphormorpholidate,
also may play a role in the apparent antiviral effect.
In more recent studies with phosphorothioate
oligomers antisense to HIV-1, strong antiviral activi-
ty has been achieved, but not with any remarkable
improvements in potency.27,28 In still another ap-
proach, phosphate-methylated oligonucleotides, i.e.
having the methyl group bound to the phosphorous
atom through an oxygen atom rather than directly
as in MP-DNA, were found to be inhibitory to HIV-1
at concentrations below 1 /uM.29
FUTURE DIRECTIONS
From available literature, it is apparent that syn-
thetic antisense DNA, especially backbone-modi-
fied, is active in the low micromolar range. At these
levels, a therapeutic dose of MP-DNA in man might
be on the order of 1 g. This would be quite a large
quantity from both monetary and production view-
points. The potency would have to be improved by
at least two or three orders of magnitude to be prac-
1014
NEW JERSEY MEDICINE
JM
Hi
ticable. This might be realized by using a DNA-drug
that catalytically degrades numerous copies of the
target strand. Stimulation of RNase digestion of a
particular mRNA might achieve this purpose. Un-
fortunately, nonionic MP-DNA, not recognizable by
enzymes, does not promote this process.30 In a clever
variation, another laboratory has demonstrated that
an oligonucleotide with a specific distribution of
phosphodiester and methylphosphonate bonds can
activate RNase H degradation of a complementary
RNA strand, while remaining nuclease resistant.31
Alternatively, the use of an active pendant group on
MP-DNA may provide the desired catalytic mech-
anism for enhanced potency. ■
REFERENCES
1. Green PJ, Pines 0, Inouye M: The role of antisense
RNA in gene regulation. Ann Rev Biochem 55:569-597,
1986.
2. Pestka S, Daugherty BL, Jung V, et al.: Anti-mRNA:
Specific inhibition of translation of single mRNA
molecules. Proc Natl Acad Sci 81:7525-7528, 1984.
3. Coleman J. Hirashima A, Inokuchi Y, et al.: A novel
immune system against bacteriophage infection using
complementary RNA (mic RNA). Nature 315:601-603,
1985.
4. Hirashima A, Sawaki S, Inokuchi Y, Inouye M: Engi-
neering of the mRNA-interfering complementary RNA im-
mune system against viral infection. Proc Natl Acad Sci
83:7726-7730, 1986.
5. Melton DA: Injected antisense RNAs specifically
block messenger RNA translation in vivo. Proc Natl Acad
Sci 82:144-148, 1985.
6. Izant JG, Weintraub H: Constitutive and conditional
suppression of exogenous and endogenous genes by anti-
sense RNA. Science 229:345-352, 1985.
7. Kim SK, Wold BJ: Stable reduction of thymidine
kinase activity in cells expressing high levels of antisense
RNA. Cell 42:129-138, 1985.
8. McGarry TJ, Lindquist S: Inhibition of heat shock
protein synthesis by heat inducible antisense RNA. Proc
Natl Acad Sci 83:399-403, 1986.
9. To RYL, Booth SC, Neiman PE: Inhibition of retro-
viral replication by antisense RNA. Mol Cell Biol
6:4758-4762, 1986.
10. Holt TJ, Gopal TV, Moulton AD, Nienhus P: In-
ducible production of c-fos antisense RNA inhibits 3T3
cell proliferation. Proc Natl Acad Sci 83:4794-4798, 1986.
11. De Benedetti A, Pytel BA, Baglioni C: Loss of (2'-5')
oligoadenylate synthetase activity by production of anti-
sense RNA results in lack of protection by interferon from
viral infections. Proc Natl Acad Sci 84:658-662, 1987.
12. Chang LJ, Stoltzfus CM: Inhibition of Rous
sarcoma virus replication by antisense RNA. J Virol
61:921-924, 1987.
13. Stephenson ML, Zamecnik PC: Inhibition of Rous
sarcoma viral RNA by a specific oligodeoxynucleotide.
Proc Natl Acad Sci 75:285-288, 1978.
14. Wickstrom EL, Bacon TA, Gonzalez A, et al.:
Human promyelocytic leukemia HL-60 cell proliferation
and c-myc protein expression are inhibited by an antisense
pentadecadeoxynucleotide targeted against c-myc mRNA.
Proc Natl Acad Sci 85:1028-1032, 1988.
15. Zamecnik PC, Goodchild J, Taguchi Y, Sarin PS:
Inhibition of replication and expression of human T-cell
lymphotropic virus type III in cultured cells by exogenous
synthetic oligonucleotides complementary to viral RNA.
Proc Natl Acad Sci 83:4143-4146, 1986.
16. Dash P, Lotan I, Knapp M, Kandel ER: Selective
elimination of mRNAs in vivo: Complementary oligodeox-
ynucleotides promote RNA degradation by an RNase H-
like activity. Proc Natl Acad Sci 84:7896-7900, 1987.
17. Dreyer GB, Dervan PB: Sequence specific cleavage
of single-stranded DNA: Oligodeoxynucleotide-EDTA-
FE(II). Proc Natl Acad Sci 82:968-972, 1985.
18. Miller PS, McParland KB, Jayaraman K, Ts’o
POP: Biochemical and biological effects of nonionic nu-
cleic acid methylphosphonates. Biochemistry 20:1874-
1880, 1981.
19. Zon G: Oligonucleotide analogues as potential
chemotherapeutic agents. Pharmaceutical Research
5:539-549, 1988.
20. Sarin PS, Agrawal S, Civeira MP, et al.: Inhibition
of acquired immunodeficiency syndrome virus by
oligodeoxynucleoside methylphosphonates. Proc Natl
Acad Sci 85:7448-7451, 1988.
21. Ebright YE, Tous GI, Tsao J, et al.: Chromato-
graphic purification of nonionic methylphosphonate
oligodeoxynucleosides. J Liquid Chromatogr 11:2005-2017,
1988.
22. Rabson AB: The molecular biology of HIV infection:
Clues for possible therapy, in Levy JA, AIDS Pathogeneis
and Treatment. New York, NY, Marcel Dekker, Inc., 1989,
pp. 231-256.
23. Fisher AG, Feinberg M, Josephs SF, et al.: The
trans-activator gene of HTLV-III is essential for virus
replication. Nature 320:367-371, 1986.
24. Goodchild J, Agrawal S, Civeira MP, et al.: Inhibi-
tion of human immunodeficiency virus replication by anti-
sense oligodeoxynucleotides. Proc Natl Acad Sci
85:5507-5511, 1988.
25. Agrawal S, Goodchild J, Civeira MP, et al.:
Oligodeoxynucleoside phosphoamidates and phos-
phorothioates as inhibitors of human immunodeficiency
virus. Proc Natl Acad Sci 85:7079-7083, 1988.
26. Zaia A, Rossi JJ, Murakawa GJ, et al.: Inhibition
of human immunodeficiency virus by using an
oligonucleoside methylphosphonate targeted to the tat-3
gene. J Virology 62:3914-3917, 1988.
27. Agrawal S, Ikeuchi T, Sun D, et al.: Inhibition of
human immunodeficiency virus in early infected cells by
antisense oligodeoxynucleotides and their phos-
phorothioate analogues. Proc Natl Acad Sci 86:7790-7794,
1989.
28. Matsukura M, Zon G, Shinozuka K, et al.: Regu-
lation of viral expression of human immunodeficiency
virus in vitro by an antisense phosphorothioate oligodeox-
ynucleotide against rev (art/trs) in chronically infected
cells. Proc Natl Acad Sci 86:4244-4284, 1989.
29. Buck MH, Koole LH, Van Genderen MHP, et al.:
Phosphatemethylated DNA aimed at HIV-1 RNA loops
and integrated DNA inhibits viral infectivity. Science
248:208-212, 1990.
30. Walder JA: Antisense DNA and RNA: Progress and
prospects. Genes Dev 2:502-504, 1988.
31. Quartin RS, Brakel CL, Wetmur JG: Number and
distribution of methylphosphonate linkages in oligodeox-
ynucleotides affect exo- and endonuclease sensitivity and
ability to form RNase H substrates. Nucleic Acids Res
17:7253-7262, 1989.
VOL. 87— NUMBER 12 DECEMBER 1990
1015
1990-1991
COMMITTEES & COUNCILS
BOARD OF TRUSTEES
(Diana C. Gore, Staff Liaison)
Angelo S. Agro, MD Haddonfield
Anthony P. Caggiano, Jr, MD Upper Montclair
Shah M. Chaudhry, MD Cape May Court House
Joel S. Cherashore, MD Nutley
Leticia V. DeCastro, MD Edison
G. Gerson Grodberg, MD Englewood
Michael M. Heeg, MD Trenton
Philip J. Jasper, MD Passaic
Louis L. Keeler, MD Haddon Heights
Edwin W. Messey, MD Willingboro
Fred M. Palace, MD Morristown
John J. Pastore, MD Vineland
Carl Restivo, Jr, MD Wayne
R. Gregory Sachs, MD Summit
Robert Schnitzlein, Student Member Union
George T. Hare, MD,
HMSS Representative Haddon Heights
George J. Neumaier, MD,
Medical Specialty
Society Representative Edison
OFFICERS
(Diana C. Gore, Staff Liaison)
Douglas M. Costabile, MD, President Murray Hill
Joseph A. Riggs, MD,
President-Elect Haddon Heights
William E. Ryan, MD,
First Vice-President Pennington
Joseph N. Micale, MD,
Second Vice-President North Bergen
Bernard Robins, MD, Secretary Union
Gerald H. Rozan, MD, Treasurer Wayne
Paul J. Hirsch, MD,
Immediate Past -President Bridgewater
JUDICIAL COUNCIL
(June O’Hare, Staff Liaison)
Paul H. Steel, MD Atlantic City
Anita Falla, MD Millburn
Louis G. Fares, MD Trenton
Alden B. Hall, MD Newton
George T. Hare, MD Haddon Heights
AMA DELEGATES
(Diana C. Gore, Staff Liaison)
Karl T. Franzoni, MD, Chairman Trenton
Joseph A. Riggs, MD, Vice-Chairman Haddon Heights
Harry M. Carnes, MD Audubon
Frederick W. Durham, MD Haddonfield
Ralph J. Fioretti, MD Rochelle Park
John S. Madara, MD Salem
Henry J. Mineur, MD Westfield
Edward A. Schauer, MD Farmingdale
Robert H. Stackpole, MD Roselle
Frank Y. Watson, MD Glen Ridge
ALTERNATE AMA DELEGATES
(Diana C. Gore, Staff Liaison)
Douglas M. Costabile, MD Murray Hill
Michael M. Heeg, MD Trenton
Paul J. Hirsch, MD Bridgewater
Donald J. Holtzman, MD Elizabeth
A. Ralph Kristeller, MD Millburn
Joseph N. Micale, MD North Bergen
Irving P. Ratner, MD Willingboro
Carl Restivo, Jr, MD Jersey City
William E. Ryan, MD Pennington
Robert J. Weierman, MD South Orange
ADMINISTRATIVE COUNCILS
Council on Legislation
(June O’Hare, Staff Liaison)
Irving P. Ratner, MD, Chairman Willingboro
Bartholomew R. D’Ascoli, MD, Vice-Chairman Sparta
L. Willis Allen, MD Millville
Michael H. Bernstein, MD Wayne
Churchill L, Blakey, MD Wenonah
Theodore H. Bodner, MD Hackensack
Edward D. Buch, MD Bridgewater
Anthony P. Caggiano, Jr, MD Glen Ridge
John P. Capelli, MD Haddonfield
Harry M. Carnes, MD Audubon
Donald J. Cinotti, MD Jersey City
William J. D’Elia, MD Spring Lake
Anthony J. DiCroce, MD Point Pleasant Beach
William V. Harrer, MD Camden
Robert A. Herbert, MD Newton
George J. Hill, MD West Orange
John C. Iacuzzo, MD Bridgewater
Louis L. Keeler, MD Haddon Heights
David I. Kingsley, MD Edison
Stephen P. Landauer, MD Newton
Howard H. Lehr, MD Gillette
Thomas Logio, MD Summit
David M. MacPeek, MD Lakewood
S. Stuart Mally, MD Atlantic City
James F. Marley, MD Dumont
Evangelos Megariotis, MD Clifton
Christopher J. Minas, MD Neptune
Jerome A. Molitor, MD Mendham
Robert M. Pallay, MD Belle Mead
Kenneth C. Peacock, MD Mount Holly
Bernard A. Rineberg, MD New Brunswick
Jay S. Rosen, MD Hackensack
Om P. Sawhney, MD South Plainfield
William D. Salerno, MD Saddle Brook
Edward A. Schauer, MD Farmingdale
Gabriel F. Sciallis, MD Mercerville
Tariq S. Siddiqi, MD Voorhees
Irving Weiss, MD Pompton Plains
Sally Ilagan, Auxiliary Member Manahawkin
Kevin J. Kerlin, MD, Resident Member Voorhees
Daniel R. Alexander, Student Member Clark
1016
NEW JERSEY MEDICINE
Jl
Anthony Ingenito, Student Member Wayne
Frank Gingerelli, MD, Consultant Hackensack
R. Gregory Sachs, MD, Consultant Summit
Angie Campo, Auxiliary Member Lawrenceville
Kenneth J. Zemanek, MD, Resident Member .... Piscataway
Paul J. Hirsch, MD, Ex-officio Member Bridgewater
Council on Medical Services
(Joseph C. Lucci, Staff Liaison)
Richard H. Sharrett, MD, Chairman North Plainfield
Robert S. Rigolosi, MD, Vice-Chairman Paramus
Alfred A. Alessi, MD Oradell
Churchill L. Blakey, MD Wenonah
Victor H. Boogdanian, MD New Brunswick
Marvin T. Boyd, MD Paterson
Joel S. Cherashore, MD Nutley
Charles L, Cunniff, MD Newark
Subash B. Duggirala, MD New Brunswick
Stephen P. Gadomski, MD Haddonfield
Ismail Kazem, MD Trenton
Monica Mehta, MD Jersey City
Emmons G, Paine, MD Voorhees Township
John J. Pastore, MD Vineland
Stanley I. Rossen, MD Park Ridge
Mark M. Singer, MD Englewood
Joseph W. Sokolowski, Jr, MD Cherry Hill
Michael L. Somerstein, MD Trenton
Matthew J. Speesler, MD Somerset
Robert H. Stackpole, MD Roselle
Narasimhaloo Venugopal, MD Vineland
Frederic E. Wien, MD Paterson
Joseph J. Doerr, MD, Resident Member Paterson
Kevin Khoudary, Student Member East Brunswick
Jack Perrone, Student Member Montclair
Joseph A. Riggs, MD, Ex-officio Member .. Haddon Heights
Council on Mental Health
(Joseph C. Lucci, Staff Liaison)
Thomas R. Houseknecht, MD, Chairman Moorestown
William R. Nadel, MD, Vice-Chairman Plainfield
Robert Berkowitz, MD Toms River
Harry H. Brunt, Jr, MD Beach Haven
Morton Friedman, MD Millburn
Terry A. Johnston, MD Margate
Eva Muller, MD Wayne
Rita R. Newman, MD Short Hills
James P. O’Neill, MD Avon-by-the-Sea
Douglas H. Robinson, MD Pennington
Gerald H. Rozan, MD Wayne
Kenneth J. Rubin, MD Long Branch
Nicholas F. Videtti, MD Ridgewood
Michael V. Will, MD West Trenton
Council on Public Health
(Joseph C. Lucci, Staff Liaison)
Charles J. Moloney, MD, Chairman Moorestown
Glenn P. Lambert, MD, Vice-Chairman Flemington
Ronald Altman, MD Trenton
David J. Blackman, MD Wayne
Mary F. Campagnolo, MD Westampton
Thomas E. Desmond, MD Edison
Stephen F. Freifeld, MD Springfield
Lawrence D. Frenkel, MD New Brunswick
Roland E. Johnson, MD Newton
Stanley R. Lane, MD Moorestown
Richard R. Lorber, MD Kenilworth
John P. Mudry, MD Ridgewood
Gerald S. Packman, MD Vineland
Barry S. Prystowsky, MD Nutley
Sorosh F. Roshan, MD Millburn
Rosi Rivas, Auxiliary Member Yardley, PA
Issa E. Ephtimios, MD, Resident Member Plainfield
William E. Ryan, MD, Ex-officio Member Pennington
Council on Public Relations
(Martin E. Johnson, Staff Liaison)
Andrew Coronato, MD, Chairman Westfield
Robert J. Biester, MD Haddon Heights
Harry H Brunt, Jr, MD Beach Haven
Ralph Cavalier, MD Northfield
Leonard J. Corwin, MD Millburn
Richard A. D’Amico, MD Englewood
Leticia V. DeCastro, MD Edison
William J. D'Elia, MD Spring Lake
Joseph A. DiLallo, MD Summit
G. Jerry Falcone, MD Jersey City
Michael M. Heeg, MD Trenton
Joseph N. Micale MD North Bergen
Charles M. Moss, MD Emerson
Kelly M. Reid, MD Pomona
Philip A, Rispoli, MD Belleville
R. Gregory Sachs, MD Summit
Aram M. Sarajian, MD Brick
Edith T. Shapiro, MD Englewood
Saul M. Tischler, MD Willingboro
Chris Kline, Auxiliary Member Plainfield
Frank J. Malta, MD, Consultant Toms River
Edwin W. Messey, MD, Consultant Willingboro
STANDING COMMITTEES
Committee on Annual Meeting
(Eileen Pfeiffer, Staff Liaison)
Donald J. Holtzman, MD, Chairman Elizabeth
Angelo S. Agro, MD Haddonfield
Thomas K. Bills, MD Lawrenceville
Thomas J. Connolly, Jr, MD Jersey City
George T. Hare, MD Haddon Heights
0. Andrei Kachala, MD Perth Amboy
Satwant G. Keswani, MD Livingston
John P. Mudry, MD Ridgewood
Philip A. Rispoli, MD Belleville
Frank R. Romano, Sr, MD Dunellen
Paul H. Steel, MD Atlantic City
Sevim Omay, Auxiliary Member Clifton
Bernard Robins, MD, Ex-officio Member Union
Committee on Credentials
(Arthur White, Staff Liaison)
Bernard Robins, MD, Chairman Union
Thomas E. Mattingly, Jr, MD,
Vice-Chairman Mount Holly
Aiden J.M. Doyle, MD Somerset
Roger C. Laauwe, MD Wayne
Thomas Logio, MD Summit
Lawrence B. Owen, MD Salem
Philip A. Rispoli, MD Belleville
Committee on Finance and Budget
(Arthur White, Staff Liaison)
Matis A. Fermaglich, MD, Chairman Teaneck
Angelo S. Agro, MD, Vice-Chairman Haddonfield
Michael M. Heeg, MD, Vice-Chairman Trenton
Julie M. Fortunato, MD Westwood
Paul J. Hirsch, MD Bridgewater
Frank L. Redo, MD Salem
Carl Restivo, Jr, MD Jersey City
Joan Rozanski, Auxiliary Member Medford
Gerald H. Rozan, MD, Ex-officio Member Wayne
Committee on Medicaid
(Joseph C. Lucci, Staff Liaison)
Churchill L, Blakey, MD, Chairman Wenonah
James Q. Atkinson, MD Vincentown
Thomas S. Bellavia, MD Hasbrouck Heights
VOL. 87— NUMBER 12 DECEMBER 1990
1017
Gertrude B. Brundage, MD East Orange
Louis G. Fares, MD Trenton
Anton P. Kemps, MD Camden
Arganey L’Avnire Lucas, Jr, MD Morristown
Bernard A. Pekala, MD Cherry Hill
William Silverman, MD Cape May Court House
Lancaster Lo, MD, Resident Member Flushing, NY
Murray Pine, DO, Consultant Newark
Saul M. Kilstein, Invited Guest Trenton
S. Eugene Yuliano, MD, Invited Guest Trenton
Martin T. Zanna, MD, Invited Guest Trenton
Committee on Medical Education
(Martin E. Johnson, Staff Liaison)
Ernest C. Hillman, Jr, MD Glen Ridge
Stanley Karp, MD Cinnaminson
Robert L. Maggs, MD Holmdel
Paul R. Megibow, MD Fort Lee
Catherine A. Michon, MD Somerdale
John C. Riggs, MD Haddonfield
Melvin L. Schulman, MD East Brunswick
Martin L. Sorger, MD Glen Ridge
John J. Sprowls, MD Rahway
Lee H. Yasgur, MD Cherry Hill
Harvey P. Yeager, MD West Orange
Joan Gering, Auxiliary Member Lambertville
Bernard Robins, MD, Ex-officio Member Union
E. Arthur Kratzman, MD, Consultant Jamesburg
Con
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Palma E. Formica, MD, Chairman Old Bridge
David E. Swee, MD, Vice-Chairman New Brunswick
Leonard Bielory, MD Springfield
William C. Black, MD Hackensack
John C. Brogan, MD Flemington
Anthony P. DeSpirito, MD Interlaken
Bruce D, Fisher, MD Plainfield
Sherman Garrison, MD Bridgeton
Richard K. Goodstein, MD Belle Mead
Brewster S. Miller, MD Somerville
Paul C. Royce, MD Long Branch
Bernardo Toro-Echague, MD Scotch Plains
Stephen F. Wang, MD Morristown
Peg Reichwein, Auxiliary Member Pennsville
Salvatore M. Moffa, MD, Resident Member .... Haddonfield
David L. Dickerman, Student Member Somerset
Alfred A. Alessi, MD, Consultant Oradell
Charles J. Heitzmann, Consultant Lawrenceville
John C. Incarvito, MD, Consultant Browns Mills
William S. Vaun, MD, Consultant Colts Neck
Committee on Medical Student Loan Fund
(Arthur White, Staff Liaison)
David J. Greifinger, MD, Chairman Belleville
Harry M. Carnes, MD Audubon
Theodora J. Maio, MD Clifton
Robert M. Pickoff, MD New Brunswick
John C. Riggs, MD Haddonfield
Committee on Membership Services
(Joseph C. Lucci, Staff Liaison)
John D. Franzoni, MD, Chairman Trenton
Angelo S. Agro, MD Haddonfield
William H. Ainslie, Sr, MD Metuchen
Donald J. Cinotti, MD Jersey City
Committee on Publication
(Geraldine Hutner, Staff Liaison)
Harry M. Carnes, MD, Chairman Audubon
Jerome Abrams, MD, MPH Edison
Richard M. Ball, MD South Plainfield
William V. Harrer, MD Camden ’
Monroe S. Karetzky, MD Newark
Clement H. Kreider, Jr, MD Ocean
John H. Lifland, MD Bridgewater
Alan J. Lippman, MD Newark
Charles P. Lisa, MD Cherry Hill -
Robert M. MacMillan, MD Philadelphia, PA
Helio J. Malinverni, MD Manahawkin
Donald W. Orth, MD Voorhees ;
Morris Soled, MD Jersey City ;
Louis S. Zeiger, MD Camden ;
LaVerne Fioretti, Auxiliary Member Paramus
Marion Geib, Auxiliary Member Haddonfield
Leonard Saltzman, Student Member Fair Lawn ;
Christopher Bibbo, Student Member Princeton
Joseph A. Riggs, MD, Ex-officio Member .. Haddon Heights
Bernard Robins, MD, Ex-officio Member Union 1
Howard D. Slobodien, MD, Ex-officio Member .... Metuchen
Committee on Revision of Constitution and Bylaws
(Diana C. Gore, Staff Liaison)
James E. George, MD, JD, Chairman Woodbury
Robert H. Gerard, MD Voorhees
Andrew Kunish, MD Fair Lawn
Kenneth N. Kunzman, MD Somerville
Pascal A. Pironti, MD Summit
Valerie Claps, Auxiliary Member Randolph
Hillel M. Ben-Asher, MD, Consultant Morristown
Henry J. Mineur, MD, Consultant Westfield
Bernard Robins, MD, Ex-officio Member Union
SPECIAL COMMITTEES
Committee on Biomedical Ethics
(June O’Hare, Staff Liaison)
Robert L. Pickens, MD, Chairman Princeton
Joseph F. Fennelly, MD,
Vice-Chairman Madison
Robert Bayly, MD Plainfield
Deborah A. Beiter, MD Somerville
Roger C. Duvoisin, MD New Brunswick
John S. Madara, MD Salem
Louis G. McAfoos, Jr, MD Westmont
Charles J. Moloney, MD Moorestown
Herman M. Robinson, MD Livingston
Rudolf E. Schwaeble, MD Mendham
M. Bernard Winkler, MD Wayne
John Winslow, MD South Orange
Allen C. Zechowy, MD Cherry Hill
Katherine H. Zimmerman, MD Moutain Lakes
Angie Campo, Auxiliary Member Lawrenceville
Charles Sperrazza,
Student Member Little Falls
Ron Tharp, Student Member Trenton
Paul Armstrong, Esq, Consultant Bridgewater
Joseph A. Cox, MD, Consultant Short Hills
Edmund L. Erde, PhD, Consultant Camden
Russell L. McIntyre, ThD, Consultant Piscataway
Geraldine Moon, Consultant Princeton
Mary Strong, Consultant Summit
Committee on Cancer Control
(Joseph C. Lucci, Staff Liaison)
George J. Hill, MD, Chairman Newark
Susan A. McManus, Vice-Chairman New Brusnwick
Roy C. Cabrera, MD Summit
Daniel Frimmer, MD Somerset
Ralph S. Greco, MD New Brunswick
Thomas C. Hall, MD Newark
Thomas F. Rocereto, MD Haddonfield
Harvey D. Rothberg, MD Princeton
Paul E. Wallner, DO Camden
Marchello Barbarisi, Student Member West Paterson
Maano Milles, DDS, Consultant Newark
George Yamane, DDS, Consultant Newark
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NEWJERSE^MEDICINE
Committee on Conservation of Vision
(Joseph C. Lucci, Staff Liaison)
Alfonse A. Cinotti, MD, Chairman Jersey City
Carl P. Bontempo, MD Long Branch
Joseph P. Calderone, Jr, MD Cranford
Vivian Chen, MD East Brunswick
Joseph M. Kaspareck, Jr, MD Somerville
Ralph C. Lanciano, Jr, DO Pennsauken
Thomas I. Rozanski, MD Sewell
Ralph A. Skowron, MD Cherry Hill
Saul M. Tischler, MD Cherry Hill
Charles J. Crane, MD, Resident Member . Philadelphia, PA
Steven Sabin, Student Member Highland Park
Daniel B. Goldberg, MD, Consultant Long Branch
Committee on Emergency Medical Care
(Joseph C. Lucci, Staff Liaison)
Rudolf E. Schwaeble, MD, Chairman Mendham
John A. Flood, Jr, MD, Vice-Chairman Trenton
Clifford B. Blasi, MD Sea Girt
Joseph R. Friedlander, MD River Edge
Charles F.V. Grunau, MD Somerville
Jack R. Karel, MD Hackensack
John J. LoCurto, Jr, MD Hackensack
J. Mark Meredith, MD Chatsworth
Dorson S. Mills, MD Elmer
Bartholomew J. Tortella, MD Newark
Nelson C. Walker, MD Hackensack
Todd M. Warden, MD Moorestown
Robert L. Wegryn, MD Elizabeth
Mary A. Willard, MD Voorhees
Michael Bavlsik, Student Member Piscataway
Elizabeth Harrington, Student Member Kearny
Joseph Kavanaugh, Consultant Martinsville
Henry R. Liss, MD, Consultant Chatham
Robert R. Scussel, Consultant Trenton
Joseph F. Slavin, Consultant Princeton
Committee on Environmental Health
(Joseph C. Lucci, Staff Liaison)
Stanley R. Lane, MD, Chairman Moorestown
Morris I. Brodkey, MD Toms River
Daniel N. Burbank, MD Cedar Grove
J. Gerard Crowley, MD Somerville
Kenneth P. Lipkowitz, MD Howell
Richard H. Musgnug, MD Medford Lakes
Alan R. Pope, MD Cherry Hill
Philip J.G. Quigley, MD Greenwich
Kenneth J. Storch, MD Union
James N. Suddeth, MD Beach Haven
John M. Tedeschi, MD Collingswood
Committee on Graduates of Non-U. S. Medical Schools
(Martin E. Johnson, Staff Liaison)
Sheldon Guss, MD, Chairman
Burton M. Feinsmith, Vice-Chairman
Carlos P. Borromeo, Jr, MD
Roy C. Cabrera, MD
Frank Campo, MD
Shah M. Chaudhry, MD
Joseph M. DeBlasio, MD
Leticia V. DeCastro, MD
William L. Diehl, MD
Pietro Enzo DiFlorio, MD
Faustino F. Estella, Jr, MD
Gino Gonnella, MD
Guillermo J. Garcia, MD
Philip J. Jasper, MD
Andrew Kunish, MD
Elmar G. Lutz, MD
Mohan C. Makhija, MD
Richard A. Michner, MD
S. Desiderio Penso, MD
Bound Brook
Westfield
Pennsauken
Summit
Lawrenceville
Cape May Court House
Hamilton Square
Edison
Morristown
Haddonfield
Voorhees
Edison
Jersey City
Passaic
Fair Lawn
Wayne
Long Branch
Cape May Court House
Brigantine
Kutumba S. Pitta, MD Toms River
Carlo Porcaro, MD Newark
Celia G. Roque, MD Cranford
Tracy Pfeifer, Student Member Cherry Hill
Committee on Long-Range Planning and Development
(A. Ronald Rouse, Staff Liaison)
Edward A. Schauer, MD, Chairman Farmingdale
Charles S. Krueger, MD, Vice-Chairman Mount Holly
Mary Blome, MD Cresskill
Donald K. Brief, MD Millburn
Robert Eidus, MD Westfield
George Leipsner, MD Maywood
Thomas C. McNamara, MD Haddon Heights
Eileen M. Moynihan, MD Woodbury
Fred M. Palace, MD Morristown
Andrea I. Reznik, MD Bridgewater
Gabriel F. Sciallis, MD Mercerville
Jean Taboada, Auxiliary Member Bricktown
Committee on Maternal and Child Care
(Joseph C. Lucci, Staff Liaison)
Thomas A. Noone, MD, Chairman Haddonfield
Gerard F. Hansen, MD, Vice-Chairman Hackensack
Peter A. Beaugard, MD Flemington
Thomas F. Bejgrowicz, MD Linden
Joseph L. DeStefano, MD Atlantic City
Stephen M. Golden, MD Summit
Caterina A. Gregori, MD Livingston
John T. Harrigan, MD New Brunswick
Thomas Hegyi, MD New Brunswick
I. Mark Hiatt, MD New Brunswick
Michael D. Horn, MD Willingboro
Ruby P. Huttner, MD Flemington
Glenn P. Lambert, MD Flemington
Courtney M. Malcarney, MD Collingswood
James P. Thompson, MD Clifton
Audrey I. Prefer, MD Bridgewater
Eric Bonifield, MD, Resident Member Port Monmouth
Edith A. Goldie, Student Member Roselle Park
George J. Halpin, MD, Consultant Trenton
Committee on Medical Aspects of Sports
(Joseph C. Lucci, Staff Liaison)
Vincent K. Mclnerney, MD, Chairman Paterson
Stuart A. Hirsch, MD, Vice-Chairman Bridgewater
Allan M. Levy, MD, Vice-Chairman Westwood
Steven G. Crawford, MD Ocean Grove
Brian C. Halpern, MD Princeton
Christine E. Haycock, MD Newark
Timothy M. Hosea, MD New Brunswick
Glenn P. Lambert, MD Flemington
Richard Levandowski, MD Pennington
Warren F. MacDonald, Jr, MD Cape May Court House
Joseph P. Pizzurro, MD Ridgewood
Walter Poprycz, MD Haddonfield
Cheryl J. Rubin, MD Bridgewater
Gary J. Savatsky, MD Paramus
David I. Scott, MD Piscataway
Aaron A. Sporn, MD Mercerville
David A. Stone, MD East Rutherford
Stephen C. Vanna, MD Maple Shade
Ron Noy, Student Member Fair Lawn
John Culberson, Student Member Bridgewater
Abner West, Consultant Short Hills
Donald Williams, Consultant Pennington
Joyce Williams, Consultant Pennington
New Jersey Health Care Committee
(Vincent A. Maressa, Staff Liaison)
Joseph A. Riggs, MD, Chairman Haddon Heights
John C. Baker, MD Northfield
Churchill L. Blakey, MD Wenonah
VOL. 87— NUMBER 12 DECEMBER 1990
1019
John P. Capelli, MD Haddonfield
Harry M. Carnes, MD Audubon
William R. Chenitz, MD Newark
Douglas M. Costabile, MD Murray Hill
Palma E. Formica, MD Old Bridge
Karl T. Franzoni, MD Trenton
George T. Hare, MD Haddon Heights
Robert R. Henderson, MD Stanton
Paul J. Hirsch, MD Bridgewater
Louis L. Keeler, MD Haddon Heights
Joseph N. Micale, MD North Bergen
Charles L. Moloney, MD Moorestown
Walter J. Pedowitz, MD Linden
Irving P. Ratner, MD Willingboro
Robert S. Rigolosi, MD Teaneck
Bernard Robins, MD Union
Gerald H. Rozan, MD Wayne
William E. Ryan, MD Pennington
Richard H. Sharrett, MD North Plainfield
Robert J. Weierman, MD South Orange
Dino Madonna, Student Member Piscataway
Committee on Physicians’ Health
(David I. Canavan, MD, Staff Liaison)
Simon D. Murray, MD, Chairman
Steven K. Allen, DO
Robert Altin, MD
William J. Annitto, MD
James A. Barnshaw, MD
Ann Beams
Natalie I. Bilenki, MD
Joseph Campagna, MD
David I. Canavan, MD
Ronald I. Forster, MD
Daniel P. Greenfield, MD
Boris G. Ivovich, MD
Glenn Jacoby, MD
Charles Kastenberg, DO
Thomas J. Liddy, MD
Herbert J. McBride, MD
Nancy McBride
George J. Mellendick, MD
Joseph L. Mooney, MD
John J. Naughton, DO
Rena Nora, MD
John J. Verdon, Jr, MD
Michael Sisack, Student Member
Princeton
Huntington Valley, PA
Cherry Hill
Rancocas
Princeton
Cranford
Morris Plains
Summit
Lawrenceville
Union
Millburn
Annandale
Bound Brook
Cherry Hill
Livingston
Toms River
Toms River
Perth Amboy
Trenton
Cinnaminson
Edison
Tinton Falls
Oaklyn
Committee on Senior Citizens
(A. Ronald Rouse, Staff Liaison)
Ian Samson, MD, Chairman
Joseph W. Bitsack, MD
Churchill L. Blakey, MD
Donald J. Cinotti, MD
Natalio Damien, MD
Ralph J. Fioretti, MD
Harlan E. Hiramoto, MD
Michael D. Horn, MD
Philip J. Jasper, MD
Joseph J. Kinney, MD
John P. Kohler, MD
A. Ralph Kristeller, MD
Nancy L. Mueller, MD
Emmons G. Paine, MD
Eugene R. Principato, MD
Marc I. Rothman, MD
Joseph J. Ryan, MD
Robert I. Salasin, MD
Teresa Schaer, MD
Andrew B. Weiss, MD
William I. Weiss, MD
Harry M. Woske, MD
Brenda E. Holcomb-Simone, DO,
Resident Member
Michael Bavlsik, Student Member
Lakewood
Hackensack
Wenonah
Jersey City
Red Bank
Rochelle Park
Bridgewater
Willingboro
Passaic
Bridgewater
Camden
Millburn
Englewood
Voorhees Township
Cherry Hill
Cherry Hill
Morristown
Cape May Court House
New Brunswick
Roseland
Livingston
Flemington
Roselle Park
Piscataway
William D. Kimler, MD, Consultant Collingswood
Mary Jane Brubaker, Consultant East Brunswick
Committee on Utilization Review Systems
(Vincent A. Maressa, Staff Liaison)
Robert J. Weierman, MD, Chairman South Orange
George T. Hare, MD, Vice-Chairman Haddon Heights
Malcolm G. Coblentz, MD Livingston
Alfio G. Dal Pan, MD Fair Lawn
Bernard Gardner, MD Hackensack
Howard J. Goldson, MD Bound Brook
Robert R. Henderson, MD Stanton
A. Ralph Kristeller, MD Millburn
Ralph J. Lewis, MD New Brunswick
Eugene Joseph Lind, MD West Orange
John J. LoCurto, Jr, MD Hackensack
Vincent T. McDermott, Jr, MD Audubon
Emmons G. Paine, MD Voorhees Township
Irving P. Ratner, MD Willingboro
Anthony M. Tonzola, MD Westfield
Elias N. Tsoukas, MD Ramsey
Committee on Women in Medicine
(A. Ronald Rouse, Staff Liaison)
Patricia G. Klein, MD, Chairman Westwood
Mary Blome, MD Englewood
Gertrude B. Brundage, MD East Orange
Christina Y. Chao, MD Medford
Leticia V. DeCastro, MD Edison
Wendy Martinez, MD Cherry Hill
Ligaya L. Prystowsky, MD Passaic
Rose P. Prystowsky, MD Nutley
Andrea I. Reznik, MD Bridgewater
Celia G. Roque, MD Cranford
Catherine E. Spears, MD Chatham
Bessie M. Sullivan, MD Edison
Carolyn W. Watson, MD Glen Ridge
Suzanne A. Widrow, MD Hanover
Edith A. Goldie, Student Member Roselle Park
Diane Pege, Student Member Newark
Committee on Young Physicians
(A. Ronald Rouse, Staff Liaison)
Joseph P. Calderone, Jr, MD, Chairman Cranford
Timothy M. Hosea, MD, Vice-Chairman New Brunswick
Dale E. Edlin, MD Red Bank
Richard K. Gadon, MD Hammonton
John E. Gatti, MD Cherry Hill
Reid A. Lachman, MD Morristown
David M. MacPeek, MD Lakewood
James P. O’Neill, MD Avon-by-the-Sea
Jorge A. Prieto, MD Woodbury
Mark D. Schlesinger, MD Hackensack
Bartholomew J. Tortella, MD Newark
Stefano R. Tarantolo, MD,
Resident Member South Amboy
Joel Braver, Student Member Somerset
Robert Schnitzlein, Student Member Union
Task Force on AIDS
(A. Ronald Rouse, Staff Liaison)
Dennis P. Quinlan, MD, Chairman South Orange
Theodore H. Bodner, MD Hackensack
David J. Gocke, MD New Brunswick
Alvin I. Kaplan, MD Bound Brook
Anthony B. Minnefor, MD Paterson
Charles J. Moloney, MD Moorestown
Joseph J. O’Connor, MD West Orange
Irving P. Ratner, MD Willingboro
Paul H. Steel, MD Atlantic City
Dorothy Espinola, Auxiliary Member Washington
Pamela J. Costello, Student Member Morristown
Richard Brennan, Esq, Consultant Morristown
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NEW JERSEY MEDICINE
Ronnie Davidson, EdD, Consultant Lawrenceville
Richard E. Dixon, MD, Consultant Trenton
Thomas D. Farrell, Consultant Trenton
Dorothy Flemming, MSN, RN, Consultant Trenton
Gloria Gary, RN, Consultant Princeton
Charles Heitzmann, Consultant Lawrenceville
Edward Johnson, MD, Consultant Newark
Rajendra Kapila, MD, Consultant Newark
Stephen C. Kimler, MD, Consultant Montclair
R. Don King, MD, Consultant Newark
Florence Kortis, Consultant Clifton
Marc Lory, Consultant Newark
Otto G. Matheke, MD, Consultant Newark
Frank Michalski, MD, Consultant Teterboro
James Oleske, MD, Consultant Newark
Elena Perez, Consultant Newark
George Perez, MD, Consultant Newark
John Sensakovic, MD, Consultant Newark
Whaijen Soo, MD, PhD, Consultant Nutley
Diane Stager, Consultant Princeton
Anthony Tarasenko, MD, Consultant Newark
Neil Williams, MD, Consultant Trenton
GENERAL CALL
TO MEMBERSHIP
The Committee on Appointments of the Medical Society of New Jersey will hold a
meeting next month to consider nominations for all MSNJ committees and councils
for the 1991-1992 administrative year. Should you wish to be considered for service
on a committee or council, please contact:
Diana Gore
Medical Society of New Jersey
Two Princess Road
Lawrenceville, NJ 08648
609/896-1766
The Medical Society of New Jersey welcomes all inquiries concerning these commit-
tee and council positions, and welcomes all who wish to serve.
VOL. 87— NUMBER 12 DECEMBER 1990
1021
Whom To Call At MSNJ Headquarters
Executive Director: Vincent A. Maressa
Address changes
Advertising (in NEW JERSEY MEDICINE)
AMA Delegation
Annual Meeting
Auxiliary, MSNJ
Biomedical Ethics
Blue Cross/Blue Shield
Board of Trustees
Continuing Medical Education
Council and Committee Appointments
Credentials
Delegates, MSNJ
DRG
Dues Payments: MSNJ and AMA
Eye Health Screening Program
Executive Committee
Financial Operations
HMOs/IPAs/PPOs
Hospital Medical Staff Relations
House of Delegates
JEMPAC
Judicial Council
Legal Services Plan
Legal Questions
Legislation
Liaison Reps to other organizations
Long-Range Planning Committee
Loss Prevention, Risk Management
Maternal and Newborn Record Books
Medical Assistants
Medical Education
Medical Services
Medical Student Loan Fund
Medicare/Medicaid
Membership Benefits
Membership Directory
Membership Records
Mental Health
NEW JERSEY MEDICINE
Nominating Committee
Officers of MSNJ
Peer Review Organization
Physicians’ Health Program
Professional Liability Insurance
Public Health
Public Relations
Resident Association
Resolutions for Annual Meeting
Senior Citizen Projects
Student Association
Subscriptions, NEW JERSEY MEDICINE
Third-Party Payor Complaints
Widows and Orphans Program
Women Membership
Joyce Guest
Joseph Cookson
Diana C. Gore
Eileen Pfeiffer
Margaret Fransckiewich
June O’Hare
Joseph C. Lucci
Diana C. Gore
Martin E. Johnson
Diana C. Gore
Mary Hamer
Eileen M. Pfeiffer
Vincent A. Maressa
Mary Hamer
Sue Arnone
Diana C. Gore
Arthur White
Joseph C. Lucci
Diana C. Gore
Diana C. Gore
June O’Hare
June O’Hare
Joseph C. Lucci
Vincent A. Maressa
June O’Hare
Diana C. Gore
Vincent A. Maressa
A. Ronald Rouse
Joyce Guest
Joseph C. Lucci
Martin E. Johnson
Joseph C. Lucci
Patricia Drakeford
Joseph C. Lucci
Joseph C. Lucci
Joyce Guest
Arthur White
Mary Hamer
Joseph C. Lucci
Geraldine Hutner
Diana C. Gore
Diana C. Gore
Vincent A. Maressa
David I. Canavan, MD
A. Ronald Rouse
Joseph C. Lucci
Martin E. Johnson
A. Ronald Rouse
Diana C. Gore
A. Ronald Rouse
A. Ronald Rouse
Nancy M. Propsner
Joseph C. Lucci
Joyce Guest
A. Ronald Rouse
1022
NEW JERSEY MEDICINE
MSNJ LIAISON
REPRESENTATIVES
Academy of Medicine of New Jersey
(1) Board of Trustees/Liaison Committee
(Liaison requested by Academy — June 19, 1966)
Sherman Garrison, MD Bridgeton
Louis L. Keeler, MD Haddon Heights
Edwin W. Messey, MD Willingboro
(2) Postgraduate Medical Education Study Committee
(Representation requested by Academy — November 15,
1964)
Palma E. Formica, MD, Chairman, Committee
on Medical Education Old Bridge
David E. Swee, MD, Member, Committee
on Medical Education New Brunswick
AIDS Education and Training Center (RAETC) for
Health Care Practitioners, New Jersey Regional
(Representation requested by UMDNJ — July 6, 1989)
Dominic A. Mauriello, MD Jersey City
AMA-Education Research Foundation
(Liaison requested by AMA — October 7, 1951)
David J. Greifinger, MD, Chairman, Committee on
Medical Student Loan Fund Belleville
Appointments, Committee on
(Established by Board of Trustees — November 20, 1988)
Joseph A. Riggs, MD, Chairman Haddon Heights
Douglas M. Costabile, MD Murray Hill
William E. Ryan, MD Pennington
Archivist-Historian
(Appointment requested by Medical History Society of
New Jersey — April 1982)
Morris H. Saffron, MD New York, NY
Audit Review Committee
(Appointed annually to review previous year’s audit)
Joel S. Cherashore, MD, Chairman Nutley
Edwin W. Messey, MD Willingboro
Fred M. Palace, MD Morristown
Gerald H. Rozan, MD, Consultant Wayne
Matis A. Fermaglich, MD, Chairman, Committee
on Finance and Budget, Consultant Teaneck
Angelo S. Agro, MD, Vice-Chairman, Committee
on Finance and Budget, Consultant ... Haddonfield
Michael M. Heeg, MD, Vice-Chairman, Committee
on Finance and Budget, Consultant Trenton
Blindness — New Jersey, National Society To Prevent
(Requested by the National Society To Prevent Blind-
ness-New Jersey — March 19, 1978)
Alfonse A. Cinotti, MD, Chairman, Committee
on Conservation of Vision Jersey City
Blood Bank Association, New Jersey
(Liaison requested by New Jersey Blood Bank Associa-
tion— April 25, 1969)
Frank Campo, MD Trenton
Blood Banking Task Force for New Jersey
(LIMDNJ — October 1981)
Frank Campo, MD Trenton
Cancer Plan, Task Force To Facilitate the
Development of a Statewide
(Representation requested by New Jersey State Depart-
ment of Health, Division of Epidemiology and Disease
Control — September 11, 1990)
Paul E. Wallner, DO Camden
Clinical Laboratory Licensing Review Panel
(Representation requested by New Jersey State Depart-
ment of Health, Clinical Laboratory Improvement Ser-
vice— August 14, 1989)
Bernard Robins, MD Union
William E. Ryan, MD Pennington
Dental Health, State Task Force for Better
(Representation requested by New Jersey State Depart-
ment of Health — January 30, 1985)
Glenn P. Lambert, MD Flemington
Diabetes Coordinating Council
(Representation requested by New Jersey State Depart-
ment of Health— November 10, 1980)
Arthur Krosnick, MD Princeton
Drug and Alcohol Problems, Statewide Committee To
Assist Local School Districts with
(Representation requested by New Jersey State Depart-
ment of Education, Regional Curriculum Services Unit-
South — June 4, 1984)
Ed Reading, MDiv Lawrenceville
Drug Utilization Review Council, New Jersey
(Representation requested by New Jersey State Depart-
ment of Health — December 19, 1984)
Harry M. Woske, MD Flemington
Education, New Jersey State Department of
(Liaison requested by assistant commissioner of educa-
tion— September 21, 1958)
Glenn P. Lambert, MD Flemington
Emergency Medical Personnel and Hospitals, Division
on Women Training Program for
(Representation requested by NJ State Department of
Community Affairs, Division on Women — August 2, 1984)
VOL. 87— NUMBER 12 DECEMBER 1990
1023
Rudolf E. Schwaeble, MD
Mendham
Executive Committee
(Provided in the bylaws, chapter III (c) )
Douglas M. Costabile, MD, President .... Murray Hill
Joseph A. Riggs, MD, President-
Elect Haddon Heights
William E. Ryan, MD, First
Vice-President Pennington
Joseph N. Micale, MD, Second
Vice-President North Bergen
Paul J. Hirsch, MD, Immediate
Past-President Bridgewater
Bernard Robins, MD, Secretary Union
Gerald H. Rozan, MD, Treasurer Wayne
Graduate Medical Education, Advisory Council on
(Representation requested by UMDNJ — 1979)
Stephen F. Wang, MD Morristown
Health Care Administration Board
(Representation appointed by MSNJ — July 1983)
A. Ronald Rouse Lawrenceville
Health Maintenance Organization Projects, Advisory
Committee To Participate in the Review of
(Recommended to executive director, Statewide Health
Coordinating Council, New Jersey State Department of
Health— 1974)
Henry J. Mineur, MD Westfield
Hospital Association, New Jersey
(Liaison established at request of New Jersey Hospital
Association — December 17, 1967)
Fred M. Palace, MD Morristown
Hospital Medical Staff Section, Governing Council
(Hospital Medical Staff Section established by 1984
House of Delegates)
George T. Hare, MD, Chairman Haddon Heights
Angelo S. Agro, MD, Vice-Chairman Haddonfield
Carlo Porcaro, MD, Secretary Newark
Francis J. Lumia, MD, Delegate Allentown
Robert L. Wegryn, MD, Alternate
Delegate Elizabeth
Harold R. Reeve, MD,
Member-at-Large Mount Holly
J. Jerome Cohen, MD, Member-at-Large .. Lakewood
Harold S. Yood, MD, Immediate
Past-Chairman Plainfield
Diana C. Gore, MSNJ Staff Liaison .... Lawrenceville
JEMPAC, Conference Committee with
(Established at request of JEMPAC — June 25, 1967)
Irving P. Ratner, MD, Chairman,
Council on Legislation Willingboro
Richard H. Sharrett, MD, Chairman, Council
on Medical Services North Plainfield
Joseph N. Micale, MD,
Second Vice-President North Bergen
Legislation
(1) Federal Keyman (Mechanism established by MSNJ —
April 4, 1954 — to serve as official intermediaries between
MSNJ and the federal legislators): 14 Congressional Dis-
trict Keymen and 2 Senatorial Keymen.
(2) State Keymen (Mechanism established by MSNJ —
July 13, 1952): Keymen in 40 Legislative Districts/21 Com-
ponent Societies.
Medical Assistance Advisory Council 1 A:
(Established at the request of the New Jersey State De- f
partment of Human Services — 1980)
James Q. Atkinson, MD Vincentown
Thomas S. Bellavia, MD Hasbrouck Heights
Medical Assistants, New Jersey Society of
(Liaison requested by Society — September 15, 1963)
Giovanni Lima, MD Kearny
Joseph C. Lucci, MSNJ Staff Liaison .. Lawrenceville
Medicare Physicians Advisory Council
(Representation requested by Pennsylvania Blue Shield —
July 15, 1990)
Louis L. Keeler, MD Haddon Heights
Richard H. Sharrett, MD North Plainfield
R. Gregory Sachs, MD Summit
Ian Samson, MD Lakewood
Si
Medical Liaison Committees I p
(High-level conference groups for discussion and consider-
ation of items of mutual interest) P
Douglas M. Costabile, MD, President .... Murray Hill
Joseph A. Riggs, MD, President-
Elect Haddon Heights
William E. Ryan, MD, First
Vice-President Pennington
Joseph N. Micale, MD, Second
Vice-President North Bergen
Paul J. Hirsch, MD, Immediate
Past-President Bridgewater
Bernard Robins, MD, Secretary Union
Gerald H. Rozan, MD, Treasurer Wayne
Vincent A. Maressa, Executive
Director, MSNJ Lawrenceville
'
(1) Medical-Dental
(Liaison requested by Dental Society — June 10, 1951)
(2) Medical-Hospital
(Liaison established by MSNJ — October 25, 1953)
(3) Medical-Legal
(Liaison established by MSNJ — October 25, 1953)
(4) Medical-Nursing
(Liaison established by MSNJ — April 4, 1954)
(5) Medical-Osteopathic
(Liaison established by Osteopathic Association — Sep-
tember 17, 1961)
(6) Medical-Pharmaceutical
(Liaison requested by MSNJ — July 26, 1953)
Mental Retardation, Governor’s Council on the
Prevention of
(Appointed by the Governor — June 22, 1984)
Stanley S. Bergen, Jr, MD Newark
Nursing Advisory Committee, New Jersey State
Department of Health
John S. Madara, MD Salem
Nursing Models Incentive Reimbursement Program
Proposals Review Panel
(Representation requested by the New Jersey State De-
partment of Health — July 12, 1989)
NEW JERSEY
MEDICINE
1024
Vincent A. Maressa
Lawrenceville
Hackensack
Osteopathic Physicians and Surgeons, New Jersey
Association of
(Invitation to attend Board meetings extended to MSNJ
president — July 24, 1986)
Douglas M. Costabile, MD, President .... Murray Hill
Pharmaceutical Assistance to the Aged and Disabled
Advisory Council
(Appointed by commissioner of the New Jersey State De-
partment of Human Services — physician representation
requested by Division of Medical Assistance and Health
Services — December 19, 1980)
Frank J. Malta, MD Toms River
Pharmacopeial Convention, The United States
(Delegate authorized to be seated — August 1988)
Joseph N. Micale, MD North Bergen
Poison Information and Education System, Advisory
Board to New Jersey
(Representation requested by New Jersey State Depart-
ment of Health — January 21, 1983)
Rudolf E. Schwaeble, MD Mendham
Radiation Protection, Advisory Committee on Nuclear
Medicine to New Jersey Commission on
(Consultants in nuclear medicine appointed by Com-
mission— November 20, 1966)
Henry J. Powsner, MD Princeton
Radiation Protection, Ad Hoc Committee on
Educational Project of the Commission on
(Appointed by Board of Trustees — November 20, 1988)
Carl Restivo, Jr, MD Jersey City
Radiation Protection, Consultant Serving New Jersey
Commission on
(Nomination for appointment to Commission requested
March 17, 1963)
Frank Gingerelli, MD
Resolutions, Committee on Annual Meeting
(Established by Board of Trustees — July 18, 1971 — to re-
view all resolutions in advance of the Annual Meeting)
Harry M. Carnes, MD, Chairman Audubon
Palma E. Formica, MD Old Bridge
Paul J. Hirsch, MD Bridgewater
Safety Council, New Jersey State
(Provided in Council bylaws — 1962)
Douglas M. Costabile, MD, President .... Murray Hill
Society for the Assistance of New Jersey Physicians
and their Families, The
(Liaison requested by Society — May 17, 1959)
Joseph R. Jehl, MD Clifton
State Board of Medical Examiners
(Trustees designated to attend monthly meetings on a
rotating basis — per Board of Trustees, December 15, 1974,
and per Board of Trustees, August 8, 1979)
Martin E. Johnson Lawrenceville
Statewide Health Coordinating Council (SHCC)
and/or its Review Committee
(Liaison established January 15, 1978 — appointed by
president of MSNJ)
A. Ronald Rouse Lawrenceville
UMDNJ, Foundation of the
(MSNJ representative appointed yearly by the Board of
Trustees to serve as a trustee, pursuant to the bylaws of
the Foundation — 1979)
Arthur Bernstein, MD South Orange
Waste Management, Advisory Council on Solid
(Appointed by governor — April 1989)
Stanley R. Lane, MD Moorestown
VOL. 87— NUMBER 12 DECEMBER 1990
1025
Second in a series
mvarewur
health are costs
going up:
?
BUG’S ARE
COSTING YOU
MONEY.
up
A patient is hospitalized with a routine kidney
problem. Four days later he’s released, with
hospital charges totaling just over $5,000. But
the bill his insurance company receives and
pays for amounts to over $52,000!
A second patient has a stone removed from
her bile duct, an endoscopic procedure
which requires only an overnight stay. But the
hospital bill she receives amounts to $6,500.
What could account for such excessive
charges? The answer is DRG’s (diagnosis-
related groups).
An experiment that failed
When government introduced DRG’s in
the early 1980’s, they were hailed as the
answer to the spiraling cost of hospital (not
physician) care in New Jersey. By having
insurers pay a standardized amount based on
the patient’s medical diagnosis, DRG’s were
supposed to bring fairness and
cost efficiency to a situation
that had few structured con-
trols. A decade
later, they have
failed to do either.
In fact, because
of its complexity,
the DRG payment
system often serves to bring about the very
situations it was designed to prevent. The
kind where a routine medical procedure can
end up costing more than 10 times the actual
charges.
You pay the tab
The reason for the excessive charges in the
first case described above was a “markup
factor” imposed to keep merging or closing
hospitals afloat while they’re winding down
their affairs. In the second case, the inflated
costs resulted from the system’s inability to
respond to newer, less expensive, health care
delivery systems developed by physicians.
Regardless of the reasons, someone has to
pay. Unfortunately that someone is you, the
employer or private individual, who feels the
squeeze in the form of higher and higher
insurance premiums.
Time for action
Let’s face it! DRG’s have not controlled the
cost of care. And by trying to standardize
payment according to diagnosis, they haven’t
assured quality patient care either. The time
has come to put an end to the DRG program
and to return to treating patients as in-
dividuals. To find out more, write to us at the
address listed below.
„ J&S8SS&
m
Your County Medical Stxiety and
The Medical Society
of New Jersey
Princess Road • Lawrenceville, NJ 08648
— taa; i -,-.r
21
La
an
1026
NEW JERSEY MEDICINE
NOTEBOOK
■ TRUSTEES’ MINUTES ■
A regular meeting of the Board
of Trustees was held on October
21, 1990, at the executive offices in
Lawrenceville. Detailed minutes
are on file with the secretary of
your county society; a summary of
significant actions follows:
Report of the President . . .
(1) JEMPAC Membership. . .
Voted to continue its unanimous
participation in JEMPAC, with
the suggestion by Dr. Riggs that all
leaders of county societies be en-
couraged to join.
(2) Unified AMA Membership
. . . Noted that 1.000 members
(out of 20,000) dropped from mem-
bership in the Pennsylvania Medi-
cal Society due to the unification
issue.
Report of Executive Director . . .
(1) MSNJ Membership . . . Was
provided with the listing of various
categories of membership in
MSNJ by county.
(2) MSNJ Financial Statements
. . . Reviewed and approved the
financial statements for the period
ending August 31, 1990.
(3) Litigation . . . Noted the fol-
lowing: decision in the medical
malpractice surcharge case
(MSNJ versus Merin) is expected
by the end of November; oral argu-
ment for the no-fault litigation still
is pending.
(4) AMA Activities . . . Noted
the following: a letter will be sent
to President Bush requesting the
resignation of Inspector General
Richard Kusserow; Pennsylvania
Medical Society is challenging the
Medicare mandatory participation
law; in regards to the antitrust case
brought by the California Medical
Society under the Health Care
Quality Improvement Act of 1986,
Mr. Maressa stated that there is
security for the physician com-
munity in federal and state laws on
immunity as long as physicians
perform in a probative, reasonable
fashion.
(5) Clinical Laboratory Im-
provement Amendments (CLIA)
1988 . . . Will be advised on all
developments regarding the
proposed regulations; in view of
the comments received by HCFA
on the proposed regulatory re-
visions related to physician office
laboratories, it is likely that there
will be serious revisions to the
proposed regulations.
6) Assistants at Surgery
(Medicare) . . . Noted that vir-
tually all of the issues regarding
assistants at surgery have been sat-
isfactorily resolved, with the ex-
ception of certain hernia proce-
dures that still are under dis-
cussion.
(7) Medical Inter-Insurance
Exchange of New Jersey . . .
Heard new MIIENJ malpractice
rates for 1991: classes J, K, and N
will enjoy a 9.67 percent decrease.
All other classes will remain at
their 1990 levels, and the subor-
dinated loan requirement for new
insureds will be suspended as the
Board of Governors petitions the
insurance commissioner for per-
mission to begin redeeming out-
standing subordinated loans.
(8) Medicare Fees . . . Heard
from Mr. Maressa that 20 of New
Jersey’s 21 counties participate in
the Senior Citizens Task Force and
that information from Penn-
sylvania Blue Shield indicates that
75 percent of all claims in New Jer-
sey are processed on an assignment
basis. Also, noted the Council on
Public Relations is releasing three
or four publications on the Medi-
care issue and that MSNJ will hold
an all-out lobbying effort to con-
tain mandatory assignment legis-
lation.
Special Reports . . . Received re-
ports from the University of Medi-
cine and Dentistry and from the
New Jersey Hospital Association.
AMA Activities . . . Heard from
AMA Trustee Palma E. Formica,
MD, on the following: regional
AMA meetings with state society
presidents, executives, and AMA
delegates are to be scheduled; a
new AMA committee to review the
activities, policies, and procedures
of the AMA Board is in place; Dr.
Formica is a member of the Nomi-
nating Committee, the Awards
Committee, and Secretary of the
AMA-ERF, and in January will be
an AMA commissioner to the Joint
Commission on Accreditation of
Health Care Organizations; de-
crease in New Jersey AMA mem-
bers; MSNJ member Nancy E.
Gary, MD, is senior medical ad-
visor of the Health Care Financing
Administration; AMA has taken a
vigorous stand in support of using
animals in laboratory research;
and FEDNET will be continued
with an initial cost of $140.
Committee on Biomedical Ethics
. . . Unanimously approved the
following:
That the Medical Society of New Jer-
sey endorse the Advance Directives for
VOL. 87— NUMBER 12 DECEMBER 1990
1029
Health Care brochure, which will be
made available to citizens and institu-
tions throughout the state.
Committee on Utilization Review
Systems . . . Approved the follow-
ing two recommendations:
That the Board of Trustees instruct
the AMA Delegation to introduce a
resolution at the 1990 Interim Meeting,
asking the AMA to petition HCFA to
revoke existing regulations which re-
quire preadmission/preprocedure ap-
proval.
That the New Jersey Congressional
Delegation be urged to support the ef-
forts of the medical community to re-
voke existing HCFA regulations which
require preadmission/preprocedure ap-
proval.
Committee on Publication . . .
Approved the following:
That the Board of Trustees approve
the renewal of Trentypo, Inc. and
Mack/Hughes Printing for the
1991-1992 production of NEW JER-
SEY MEDICINE , and that a study of
paper grades and costs be initiated.
State Board of Medical Exam-
iners . . . Noted the following re-
port from Michael B. Grossman,
DO, SBME president: retirement
of public member Ruth Ballou
from SBME; regulations to direct
the activities of the review panel as
stated in the Professional Medical
Conduct Reform Act of 1989 are in
draft phase; panels of consultants
will be necessary due to the
escalating volume of cases; SBME
and MSNJ are in agreement that
all physical therapy should be
prescribed by a physician; and a
report by the Task Force In-
vestigating the Impact of Third-
Party Payors under the chair-
manship of Frank J. Malta, MD,
is forthcoming.
New Business . . . Decided the
following matters: from Bergen
County Medical Society — denied
request for funding to assist with
Annual Meeting expenditures; and
will investigate cost and feasibility
of an 800 number for MSNJ; from
Morris County Medical Society —
referred to the Judicial Council for
review and recommendation the
matter requesting MSNJ to ad-
dress the issue of how county medi-
cal societies can deal with the
growing expenses involved in ad-
ministering their regulations; and
approved formal liaison with the
New Jersey Pediatric Society. □
International Training Program
Established. A $2.25 million gift
from a Swiss charitable foundation
will create the first international
program to train health care pro-
fessionals to treat children with
AIDS and also will benefit pedi-
atric AIDS research in Newark.
The program will be operated by
UMDNJ-New Jersey Medical
School and Children’s Hospital at
United Hospitals Medical Center.
The gift, from the Association
Francois-Xavier Bagnoud, also
will endow an academic chair at
the medical school for Dr. James
M. Oleske, a professor of pediatrics
and an internationally recognized
researcher and clinician who was
one of the first to identify the AIDS
virus in children. Dr. Oleske will
be the program medical director.
CABM Dedicated at Piscataway
Campus. Governor Jim Florio
joined industry executives and
academic officials to dedicate the
new Center for Advanced Bio-
technology and Medicine (CABM)
in Piscataway. The event marked
the completion of New Jersey’s
premier facility devoted to medical
advances through research in
molecular biology. CABM, a joint
project of Rutgers and UMDNJ
and a principal program of the
New Jersey Commission on Sci-
ence and Technology, sponsors 11
advanced technology research
centers on university campuses
throughout the state. Constructed
at a cost of $30 million, the
112,000-square-foot CABM facility
eventually will house 180 re-
seachers and staff members work-
ing to understand the causes and
cures for such serious illnesses as |Cr
cancer, AIDS, and Alzheimer’s dis- n
ease. |an
Hard Work Poses No Risk To Jsk
Fetus. Although women in physi- |cti
cally strenuous jobs often feel com- L
pelled to reduce their activities |ar
during pregnancy, a new study of |gt
pregnant hospital physicians
found that long hours in a stressful .
occupation posed no risk to the de- L'
veloping fetus.
The study, published in The
New England Journal of Medicine,
was conducted by Dr. George C.
Rhoads, endowed professor of pub-
lic health at UMDNJ-Robert
Wood Johnson Medical School,
and researchers from the National
Institute of Child Health and
Human Development and the
David and Lucille Packard Foun-
dation.
Device Helps Deaf Obtain Den-
tal Care. UMDNJ has installed a
Telecommunications Device for
the Deaf (TDD) telephone line, be-
coming only the second health sci-
ences institution in the nation to
offer this service. This device al-
lows deaf and hearing-impaired
patients to communicate with the
UMDNJ-New Jersey Dental
School, Newark, without the use of
a deaf contact or hearing person.
The TDD consists of a typewriter
keyboard and video monitor con-
nected to the phone line. Both the
caller and receiver communicate
by typing messages back and forth.
The dental school TDD number is
201/504-7751.
Surgery Helps Children with
Facial Deformities. Children with
facial defects caused by congenital
conditions now can receive help
from the Craniofacial Reconstruc-
tion Program — the first of its kind
in the state — at UMDNJ-Robert
Wood Johnson Medical School,
New Brunswick.
Neurosurgeons and plastic sur-
geons in the new program literally
can reshape the skulls of children
born with abnormalities associated
with such congenital conditions as
Down’s and Apert’s syndromes.
lUMDNJ NOTESI
1030
NEW JERSEY MEDICINE
Craniofacial reconstruction can re-
pair defects such as bulging eyes
and foreheads and misshapen
skulls. The program is aimed at
children; however, adults who
have been disfigured from trauma
and cancer also can be treated. □
Stanley S. Bergen, -Jr., MD
■PRESIDENTIAL ADDRESS!
The following speech was writ-
ten by Paul J. Hirsch, MD, upon
completion of his term as MSNJ
president:
I feel privileged and honored to
address you today, and to report to
you on our activities during the
past year.
We have continued to follow our
mission as indicated in the con-
stitution of the Medical Society of
New Jersey: “To promote the bet-
terment of the public health ... to
enlighten public opinion . . . and
to safeguard the rights of the prac-
titioners of medicine.”
Very few of the activities of any
organization begin and end neatly
within the organizational year.
During the past year, the Medical
Society of New Jersey has initiated
some programs, concluded others,
and remains in the midst of many
more.
We are vitally concerned about
the potential crisis in health care
in our state and in the nation. The
number of patients in New Jersey
with AIDS continues to climb
tragically. Our Task Force on
AIDS continues to grapple with
the important and sensitive issues
that arise from this awful disease,
a disease that presents us with the
greatest public health challenge we
now face. We believe that the pub-
lic does not understand the im-
mensity and the enormity of the
tragedy that awaits us, in loss of
life, human suffering, and eco-
nomic costs.
Even now, there is a shortage of
physicians available to treat AIDS
patients, and to treat some other
disadvantaged patient groups. In
part, this relates to the lack of
funding for medical care for these
groups, thereby depriving them of
accessible medical care. Our Task
Force on Patient Care for the
Under-Insured even now is de-
veloping strategies to deal with
this situation.
In New Jersey, there also is a
shortage of nursing and other
health care workers. We continue
to deal with this problem, and to
evaluate potential solutions,
through our Task Force on the
Shortage of Nurses and Technical
Personnel.
Our environment very directly
affects the health of our citizens
and the quality of life in New Jer-
sey. Our Committee on En-
vironmental Health has become a
respected voice among those con-
cerned with the destruction that
man may wreck on the land, the
water, and the air we breathe.
Your Medical Society continues
to represent our profession on these
and other important issues, in the
councils of state and national gov-
ernment.
In order to effectively represent
the physicians of New Jersey, we
must avoid fragmentation of our
profession, and we must broaden
our ranks. Last year, I promised
this House of Delegates that we
would give meaningful partici-
pation within our organization
to other physician groups. Your
Board of Trustees has taken spe-
cific steps to accomplish this goal.
We have provided observer status
on our Board, for a representative
from the specialty societies, and
for a representative from the New
Jersey Hospital Medical Staff Sec-
tion. We believe that these ad-
ditional voices have strengthened
our Medical Society. This trial
program has been so effective that
the Board now has referred this to
the Committee on Constitution
and Bylaws, to formalize this rela-
tionship.
Your Board of Trustees has dis-
cussed the potential fragmentation
of physicians that would occur
with so-called unified, or man-
datory, membership in the Ameri-
can Medical Association. The
Board is opposed to mandatory
AMA membership while encourag-
ing voluntary membership in our
national organization. We believe
that any program of mandated
membership will be harmful to the
Medical Society of New Jersey,
harmful to the American Medical
Association, and harmful to our
profession. This House of Dele-
gates has rejected mandatory
membership in the past. It has
recognized the problems that other
states have faced and continue to
face through this onerous program.
I hope that mandatory member-
ship will not be an issue in New
Jersey in the future; and if it is, I
will personally oppose and fight it.
One of the most important goals
of our Board of Trustees has been
to revitalize and organize our pro-
cess of long-range or strategic plan-
ning. In my inaugural address, I
promised we would make progress
in this effort, and that I would re-
port to you at this time.
Long-range planning is essential
if an organization is to recognize its
needs, identify alternatives, and
plan for the use of finite resources
to attain its goals.
Strategic planning is a process of
dealing with today’s problems
today, so that we will be ready to
deal with tomorrow’s problems. It
is a process of programming
change, to maintain our options. It
is a process of recognizing patterns,
to provide continuity and con-
sistency. It is a process by which
we adopt careful planning, and
avoid reactive tactics.
During this past year, the Com-
mittee on Long-Range Planning
developed a strategic plan to guide
this Medical Society as we face our
future challenges. The Committee
and the Board of Trustees held a
retreat to review and discuss this
plan, which has now been adopted
by the Board.
But, the process is not complete,
and never will be: this is a living
document, and it will be re-evalu-
VOL. 87— NUMBER 12 DECEMBER 1990
1031
ated and modified as required. The
Board of Trustees will use this plan
as a guide to policy, and in the
development of programs.
Communication with our mem-
bership is a major priority of this
Medical Society. We believe that
this communication has improved
and will continue to make this ef-
fort. We have communicated
through our standard measures,
through increased frequency and
distribution of the MSNJ Hotline,
with frequent communications re-
garding current issues, and with
the “Newswatch” page added to
NEW JERSEY MEDICINE. The
leadership conference in Novem-
ber was a great success, and
provided an opportunity to review
programs and policies, between
meetings of the House of Del-
egates. We have adopted a plan
that we hope will provide FAX ma-
chines for every county medical so-
ciety office, to improve the speed
and frequency of communications
to these essential components of
our organization.
Health policy is an over-
whelming concern of the Medical
Society of New Jersey. It is only by
involvement in the formulation of
health policy, and related public
policy, that we can truly defend
and advance the cause of ac-
cessible quality care for our pa-
tients.
The Board of Trustees is com-
mitted to political activity. This
past year, your Board was proud to
attain 100 percent membership in
JEMPAC, and we urge similar
commitment from each of you.
During the past year, the Medi-
cal Society’s legislative and regu-
latory initiatives have continued.
The Board of Trustees held a
state legislative seminar to meet
with leaders of our state legislature
and to discuss our mutual con-
cerns.
The executive committee
traveled to Washington, and met
with many of our legislators, and
with the health aides of every sena-
tor and congressman from New
Jersey. We already have seen
direct benefits of these meetings,
and this expanding program will
provide increasing benefits in the
years to come.
We have learned that we can be
most effective when we set pri-
orities, and use our resources in
those areas most important to us
and to our patients.
Some of these priorities are evi-
dent.
Any proposal requiring man-
datory assignment of Medicare
claims will decrease the access to
care of our senior citizens, and de-
crease the quality of the care avail-
able to them. We are constantly
ready to meet this challenge. We
have defeated it in the past and
will win again in the future.
We oppose the expansion of
license and scope of practice of
other health workers through legis-
lation and regulation, rather than
by education. We oppose this in all
instances and will continue to fight
every such battle.
Tort reform continues to be a
priority for your Medical Society,
as well as the Medical Inter-In-
surance Exchange of New Jersey.
During this past year, we have
been particularly pleased with our
success in markedly reducing the
medical waste regulation fee for
most physicians, from $528 to
$100. This measure alone will save
for each member of our Society a
dollar amount greater than our an-
nual dues.
We also have been pleased with
the success of the Codey legislation
for physician licensure reform, that
accomplished virtually all of our
goals; and we will continue to
pursue further improvements in
the law.
Litig-ation increasingly has
played a role in our efforts on your
behalf. Litigation, with its uncer-
tain outcome, always is a last re-
sort. But we will not hesitate to use
this mechanism to protect the
rights of the physicians of New Jer-
sey.
We continue to litigate against
the insurance commissioner with
regard to the outrageous pro- 1
fessional liability surcharge. Our
initial efforts resulted in a 50 per- :
cent decrease in this surcharge for ial
most of our members, from 5 per- jcl
cent to 2V% percent. But, we will
not rest until we have eliminated
this unfair, unreasonable tax on
our membership.
We have continued our litigation
against the State Board of Physical
Therapy, to prevent the expansion
of practice of physical therapists j
into areas for which their educa- |a
tion does not prepare them. We
won this battle in the lower courts; •} a
we now continue it at the Supreme | s
Court level.
Reluctantly, we are involved in
litigation with the PRO to protect t
the full rights of our membership
to legal counsel and legal represen-
tation at all stages of inquiry by
the PRO.
During the past year, the Medi-
cal Society of New Jersey has had
ongoing meetings with Penn-
sylvania Blue Shield, and the
Health Care Financing Adminis-
tration (HCFA), to iron out dif-
ficulties between Pennsylvania
Blue Shield and the physicians.
Some problems have improved sig-
nificantly; others have not been re-
solved. We will continue to work on
your behalf in this area. In order to
do so, you must bring your prob-
lems to the attention of the Medi-
cal Society, and we urge that you
contact the office of Joseph Lucci
with specific problems and details
as they arise.
Physician assistants are once
again, and still, an issue for us to
face. The Medical Society has
spent more than a decade oppos-
ing— correctly, I believe — the con-
cept of the so-called physician as-
sistant. This historically has been
a proposal for a physician sur-
rogate, not an assistant. On this
basis, our House of Delegates, in
an emergency session, opposed this
concept; and we have continued to
oppose it. I am proud that New
Jersey, alone among all 50 states,
NEW JERSEY MEDICINE
1032
has no licensed physician assis-
tants.
Our position has not changed.
But, the proposal has changed,
and the arena in which it is dis-
cussed has changed.
The concept of physician assis-
tants previously has arisen in the
Legislature. It now has been placed
within the realm of the State
Board of Medical Examiners.
There is no longer a question of
“licensing” physician assistants; it
is now a matter of “delegation” for
an assistant to function through
the license of the doctor, and now
as a true assistant rather than a
surrogate.
The State Board of Medical
Examiners has indicated its inten-
tion to proceed with some form of
physician assistants in New Jer-
sey. And, many of our members,
many members of this House of
Delegates, now are requesting ad-
ditional ancillary personnel.
This then has been the decision
facing us. Not: Do we oppose phy-
sician assistants? We do! Rather:
Should we participate and nego-
tiate within this process, in order
to have a meaningful impact on
the outcome? I believe we must!
We must participate; we must
play a role; we must guide this pro-
cess. I do not believe that the
Medical Society of New Jersey can
stand aside in any debate involv-
ing our profession or the health of
our patients. We must insist upon
regulation of these assistants that
would provide additional protec-
tion for our patients. We believe
that any trial in the use of phy-
sician assistants must be limited to
a pilot study, and the scope of their
responsibilities meaningfully re-
stricted to protect the welfare of
our patients. If there are to be
physician assistants, they must as-
sist physicians, not replace them.
Your officers and the Board of
Trustees need the guidance and
direction of this House of Del-
egates. But, I ask that you not tie
the hands of your elected represen-
tatives, by forbidding any response
to the challenges before us, by for-
bidding negotiation on your behalf.
You should not prohibit the par-
ticipation of the Medical Society of
New Jersey in the regulatory pro-
cess that is occurring. Allow your
elected leadership to work on your
behalf, on behalf of the physicians
of New Jersey, to obtain the best
of all possible regulatory programs.
One of the finest actions of the
Medical Society of New Jersey has
been the formation of a pro-
fessional liability insurance com-
pany: really two companies,
MIIENJ and its “management”
company, the New Jersey State
Medical Underwriters. We are
proud of the financial strength of
MIIENJ, and proud that this com-
pany could recently return an 11
percent refund on the 1978
premium year, and proud that
premiums have remained level for
the past three years, without an
increase, and indeed with a small
reduction in premium for the cur-
rent year.
During the past year, the mem-
bers of the Board of Directors of
the Underwriters, and the Board of
Governors of MIIENJ, agreed that
we should re-evaluate the claims
management approach and activi-
ty. An outside consulting firm per-
formed a study, and has rec-
ommended programs and policies
to enhance and improve our in-
surance company.
The report has been dealt with
forthrightly and honestly, and will
benefit the insureds of the com-
pany and the members of this so-
ciety.
In order to add to the strength
and depth of the company, and to
the relationship of “our insurance
company” with the Medical So-
ciety of New Jersey, the Board of
Trustees has added five new mem-
bers to the Board of Directors of
the New Jersey State Medical
Underwriters. In some other states,
the ties between a state medical
society and the professional lia-
bility carrier it formed, have been
weakened, in some states, a hostile
or antagonistic relationship has de-
veloped. That will not happen in
New Jersey.
If MIIENJ and the Underwriters
have required a great deal of the
time and attention of the Board of
Trustees during the past year,
another of our important programs
has required virtually none. The
Physicians Health Program, under
the guidance and leadership of
David Canavan, MD, is the finest
such program in this country
today. It is the standard that all
other state programs seek to
emulate. This program saves lives
and careers, protects and benefits
our members, and protects the
public. It is a service we provide
not only for our members but for
all physicians, and a service we
provide for the citizens of New Jer-
sey.
In conclusion, may I express my
personal gratitude for the privilege
of having served as president of
this Medical Society; my gratitude
to the Board of Trustees for their
support, their work, their dedi-
cation to their tasks; my gratitude
to this House of Delegates, of
which I have been a member for so
many years, which I remain a part
of, and which I hope to remain
with, for many, many years.
I appreciate your efforts, and
your concerns, and I appreciate
your trust and confidence in me.
To each of you I say thank you for
your support, thank you for your
guidance, and thank you for your
friendship. □
NEW MEMBERS —
The Medical Society of New Jer-
sey would like to welcome the fol-
lowing new members:
Bergen County
Lewis M. Attas, MD
Robert L. Berkowitz, MD
Raymond D. Reiter, MD
Samuel J. Snyder, MD
Reynol Suarez, MD
Burlington County
Barbara A. Bernstein, MD
Christopher J. Boynton, MD
Daniel A. D’Auria, MD
VOL. 87— NUMBER 12 DECEMBER 1990
1033
Joseph J. Heether, MD
Elizabeth A. Paczolt, MD
Raul A. Trillo, Jr, MD
Susan Trillo, MD
Camden County
David L. Clair, MD
Michael B. Herlich, MD
Christina G. Rehm, MD
Samuel I. Sarmiento, MD
Jeffrey M. Wahl, MD
Cape May
Mahaveer P. Prabhakar, MD
Essex County
Kevin R. Free, MD
Terrance H. Lee, MD
Steven M. Lomazow, MD
Calvin C. Matthews, MD
Eric Munoz, MD
Jules Pean, MD
Leon N. Sussman, MD
Robert F. Traflet, MD
David S. Zakheim, MD
Hudson County
Yodalio Cabaleiro, MD
Juan A. Gonzalez, MD
Isabelle M. Thomas, MD
Richard Valdesuso, MD
Hunterdon County
Salvatore J. D’Angio, MD
Mercer County
Ramon T. Bobila, MD
Robert A. Donohue, MD
Dan R. Gerstenblitt, MD
Richard D. Gordon, MD
George F. Gushue, DO
Charles N. Jeck, DO
Wayne S. Kubal, MD
Ronald W. Li, MD
Hank R. Lubin, MD
Robert F. Meirowitz, MD
Denise K. Shusterman, MD
Bruce Siegel, MD
Jaya Subramoni, MD
John D. Tydings, MD
Robert H. Wood, MD
Peter I. Yi, MD
Middlesex County
Brad J. Cohen, MD
Julie Ganifas, MD
James P. Lamprinakos, MD
Philip Mach, MD
Douglas M. Solonick, MD
Jack A. Stroh, MD
Monmouth County
Ellen M. Cosgrove, MD
John E. Fitzpatrick, MD
Mark I. Sisskin, MD
Christopher S. Tolerico, MD
Alfred F. Wolkomir, MD
Morris County
Eve S. Benvenuti, MD
Ian J. Gluck, MD
John C. Hahn, MD
Veronique C. Hubert, MD
Marta Meyers, MD
Deborah Pasik, MD
Arthur F. Santiago, MD
Scott N. Schafrank, MD
Neal D. Shore, MD
Stanley J. Skoczylas, MD
Mark H. Stein, MD
Ocean County
Stephanie P. Argyris, MD
Alison F. Carter, MD
Rosalinda 0. Espineli, MD
Daniel E. Fox, MD
Howard D. Geller, MD
S. Moosa Jaffari, MD
Vasant P. Kate, MD
Brian S. Kerr, MD
Charles R. Markowitz, MD
Chakrapani T. Prakash, MD
William D. Strazzella, DO
Kock-Yen Tsang, MD
Neal J. Winzelberg, MD
Passaic County
Scott L. Coleman, MD
Ayad K. Jihayel, MD
Somerset County
Joseph A. Donnellan, MD
Ronald G. Nahass, MD
Union County
Alan P. Krieger, MD
■i PLACEMENT FILEHH
The following physicians have
written to the executive offices of
MSNJ seeking information on pos-
sible opportunities for practice in
New Jersey. The information has
been supplied by the physicians. If
you are interested in any further
information concerning these phy-
sicians, we suggest you make in-
quiries directly to them.
ANESTHESIOLOGY
Michael Silverberg, MD, 2020 Walnut
St., Apt. 29K, Philadelphia, PA 19103.
Yale 1983. Board eligible. Group or
hospital. Available July 1991.
CARDIOLOGY
George D. Birmingham, MD, 3531
Salerno Ct., Apt. 5, Middleton, WI
53562. Mount Sinai 1984. Board
eligible. Board certified (IM). Group or
partnership. Available July 1991.
INTERNAL MEDICINE
Anan Adnan Faidi, MD, 30 Charles St.
W, Apt. 1717, Toronto, Ontario, IM4Y
1R5 Canada. Jordan 1983. Board certi-
fied. Also, board eligible (ENDO-
CRIN). Group. Available.
Marc Kesselhaut, MD, 1 Rustic Ridge,
C16, Little Falls, NJ 07424. St.
George’s Llniversity 1986. Board
eligible. Solo or partnership in Mercer, Al
Somerset, Burlington, Hunterdon, or j,
Middlesex County. Available.
Suresh Reddy, MD, 3301 Cobblestone
Cir., #6, Waterloo, IA 50703. Kakatiya
(India) 1980. Board certified. Board
eligible (GASTRO). Group, partner- |'
ship, solo. Available.
NUCLEAR MEDICINE
Haresh P. Solanki, MD, 3 West Elm
St., Islip, NY 11751. MP Shah Medical
College (Iran) 1980. Board eligible. 1
Group or hospital based. Available.
PEDIATRICS
Donna Churlin, MD, 55 Montgomery
St., Bloomfield, NJ 07003. UMDNJ
1987. Board eligible. Partnership or
group in central New Jersey (Essex,
Llnion, or Morris Counties). Available
July 1991.
PHYSICAL MEDICINE
AND REHABILITATION
Robert B. Thorne, MD, 112 Wood-
side Ave., Trenton, NJ 08618. Rutgers
1980. Board certified. Part time or full
time. Available.
SURGERY
Donna Vecchione, MD, 27700 Bishop
Park Dr., 4025, Willoughby Hills, OH
44092. SUNY-Stony Brook 1985.
Board eligible. Partnership, solo,
multispecialty group. Available.
UROLOGY
Ronald G. Frank, MD, 380 Rector PL,
Apt. 1 1 J, New York, NY 10280. New
York Medical 1985. Group or partner-
ship. Available July 1991.
Jeffrey L. Gevirtz, MD, 400 Narra-
gansett Pkwy., Apt. SC7, Warwick, RI
02888. UMDNJ-Robert Wood Johnson
Medical School 1986. Board eli-
gible. Group or partnership. Available
July 1991.
S. Misra, MD, 8161 Gatewood Dr.,
Clay, NY 10341. SCB-Orissa (India)
1977. Board eligible. Group or partner-
ship. Available July 1991.
1034
NEW JERSEY MEDICINE
ANESTHESIOLOGY
January
15 Meeting
6- 9 P.M. — Ramada Inn, Clark
(New Jersey State Society
of Anesthesiologists)
17 Geriatric Anesthesia
8-9 A.M. — Dover General
Hospital, Dover
(AMNJ)
February
1- Advances in Pain Management
3 Yacht and Beach Club,
Walt Disney World,
Lake Buena Vista, Florida
(UMDNJ)
DERMATOLOGY
January
8 Nail Disease
7- 9 P.M. — Schering Corporation,
Kenilworth
(Dermatological Society of
New Jersey)
16 Case Presentations
6- 9 P.M — RCHP, US #1,
New Brunswick
(UMDNJ, Division of
Dermatology)
February
12 Liposuction
7- 9 P.M. — Schering Corporation,
Kenilworth
(Dermatological Society of
New Jersey)
13 Common Dermatoses
1:30-2:30 P.M. — Runnells
Specialized Hospital,
Berkeley Heights
(AMNJ)
INFECTIOUS DISEASE
January
9 Diagnosis and Treatment of
AIDS
10:30-11:30 A.M.— Christ
Hospital, Jersey City
(AMNJ and NJDOH)
9 Diagnosis and Treatment of
AIDS
11:30 A.M. -12:30 P.M.— Rahway
Hospital, Rahway
( AMNJ and NJDOH)
9 Diagnosis and Treatment of
AIDS
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ and NJDOH)
1 1 Identification and Management
of Asymptomatic HIV-Infection
10-11 A.M. — Marlboro Psychiatric
Hospital, Marlboro
(AMNJ and NJDOH)
23 Diagnosis and Treatment of
AIDS
12 Noon-1 P.M. — Union Hospital,
Union
(AMNJ and NJDOH)
30 Identification and Management
of Asymptomatic HIV-Infection
12 Noon-1 P.M. — Union Hospital,
Union
(AMNJ and NJDOH)
February
13 Diagnosis and Treatment of
AIDS
9-10 A.M. — Elizabeth General
Medical Center, Elizabeth
(AMNJ and NJDOH)
MEDICINE
January
2 Hyperalimentation
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
8 Internal Medicine Update and
15 Board Review
22 5:30-7:30 P.M. — Cooper Hospital/
29 University Medical Center,
Camden
( Cooper Hospital/University
Medical Center)
8 Topics in Public Health
16 12:15-1:30 P.M.— Health and
Agriculture Building, Auditorium,
Trenton
(NJDOH and AMNJ)
9 Diabetic Retinopathy
1:30-2:30 P.M. — Roosevelt
Hospital, Edison
(AMNJ)
9 Diabetic Nephropathy
2-3 P.M. — Welkind Rehabilitation
Hospital, Chester
(AMNJ)
9 Living Wills
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
9 Hypertension — New Drug
Regimens
2:30-3:30 P.M. — Ancora
Psychiatric Hospital,
Hammonton
(AMNJ)
10- Sinus Endoscopy
11 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
14 Diabetic Nephropathy
1-2 P.M. — New Lisbon
Developmental Center,
New Lisbon
(AMNJ)
15 Beyond Correction of Anemia —
Erythropoietin in the ESRD
Patient
6:30-9:30 P.M. — Overlook
Hospital, Summit
(Nephrology Society of
New Jersey)
15 Asbestos-Associated Diseases
8-9 A.M. — Underwood Memorial
Hospital, Woodbury
(AMNJ)
16 Diabetic Nephropathy
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
16 Internal Medicine
23 Review Course
30 4-7 P.M. — University Hospital,
New Brunswick
(AMNJ and UMDNJ)
16 Current Chemotherapy
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
17 New Treatment Modalities and
Implications for the Future in
Diabetes
10-11 A.M. — Hunterdon
Developmental Center,
Clinton
(AMNJ)
18 Juvenile Onset Diabetes
8-9 A.M. — Dover General
VOL. 87— NUMBER 12 DECEMBER 1990
1037
r
PHILADELPHIA HEART INSTITUTE
Presbyterian Medical Center
I Cardiology
Update
designed for the physician and provides an intensive
survey of the current status of clinical cardiology . . .
Wednesday, January 9, 1991
Stroke: Diagnosis and Management in the 1990's
Moderator: Ami E. Iskandrian, M.D.
3:00-3:30
The natural history of chronic atrial fibrillation
and the prevention of strokes
J. David Ogilby, M.D.
3:304:00
Diagnosis and management of symptomatic and
asymptomatic carotid bruits in patients
undergoing cardiac surgery
William G. Hendren, M.D.
4:00-5:00
Case Presentations
Panel Discussion
Vasanth K. Bethala, M.D.
Robert 1. Katz, M.D.
J. David Ogilby, M.D.
Terry Langer, M.D.
GaryJ. Vigilante, M.D.
Stephen J. Nierenberg, M.D.
■ Case Presentations and Panel Discussions
■ CME Credits *
■ bio Registration Fee
■ Call for Reservation 215-662-8627
Scheie Auditorium
Presbyterian Medical Center
39th & Market Streets
Philadelphia, Pennsylvania 19104
Presbyterian Medical Center is an affiliate of the University of Pennsylvania.
*Presbyterian Medical Center designates this continued medical education activity for 2 credit hours in Cat-
egory I of the Physicians' Recognition Award of the American Medical Association and the Pennsylvania Medical
Society Membership requirement. Mine sessions, 19 credits.
\
1038
NEW JERSEY MEDICINE
Hospital, Dover
(AMNJ)
23 Peptic Ulcer Disease
2:30-3:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(AMNJ)
24 Visiting Professor Lecture
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center )
25 Detoxification: Commonly Used
Drugs
10-11 A.M. — Marlboro Psychiatric
Hospital, Marlboro
(AMNJ)
30 Chronic Epstein-Barr Virus
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
February
1 Living Wills
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
2 Podiatry Meeting
8 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
2- 8th Annual Pain Management
5 8 A.M. -1P.M. — Walt Disney
World, Lake Buena Vista, Florida
(UMDNJ)
5 Fifth Annual Internal Medicine
12 Update and Board Review
19 5:30-7:30 P.M. — Cooper Hospital/
26 University Medical Center,
Camden
( Cooper Hospital/University
Medical Center)
5 Issues in Public Health
19 12:15-1:30 P.M.— Health and
Agriculture Building, Auditorium,
Trenton
(NJDOH and AMNJ)
6 Living Wills
10:30-11:30 A.M. —Christ
Hospital, Jersey City
(AMNJ)
6 Internal Medicine Review
13 Course
20 4-7 P.M. — University Hospital,
27 New Brunswick
(AMNJ and UMDNJ)
6 Diabetes in Pregnancy
11:30 A.M. -12:30 P.M.— Rahway
Hospital, Rahway
(AMNJ)
6 Nonoperative Management of
Chronic Back Pain
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
8 Diabetic Nephropathy
1-2 P.M. — North Princeton
Developmental Center, Princeton
(AMNJ)
11 DRG/Cost Containment
7-8 P.M. — Wallkill Valley General
Hospital, Sussex
(AMNJ)
12 Internal Medicine Update and
19 Board Review
26 5:30-7:30 P.M. — Cooper Hospital/
University Medical Center,
Camden
( Cooper Hospital/University
Medical Center)
13 Learning Disabilities
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
13 Chronic Epstein-Barr Virus
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
15 Neuro-Ophthalmology
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
20 Managing Stress Effectively
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
2 1 Prevention of Lower Extremity
Amputations
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
28 Visiting Professor Lecture
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Saint Barnabas
Medical Center)
OBSTETRICS/GYNECOLOGY
January
9 Estrogen Replacement Therapy
10:30-11:30 A.M. — St. Mary’s
Hospital, Passaic
(AMNJ)
1 1 Postoperative Toxic Shock
Syndrome
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
14 Adolescent Menstrual Disorders
12 Noon-1 P.M. — Warren
Hospital, Phillipsburg
(AMNJ)
18- 4th Annual Practice Approaches
21 to Obstetrics and Gynecology
7:30A.M.-1 P.M. — Cozamel,
Mexico
(UMDNJ)
25 Diabetes in Pregnancy
7:30-8:30 A.M. — Kennedy
Memorial Hospital,
Washington Township
(AMNJ)
February
17- Current Issues and Advances in
20 Women’s Health Care
7:30 A.M.-l P.M. — Walt Disney
World, Lake Buena Vista, Florida
(UMDNJ)
ARE YOU MOVING?
if so, please send a change of address to NEW JERSEY MEDICINE,
Medical Society of New Jersey, Two Princess Road, Lawrenceville,
NJ 08648, at least six weeks before you move.
Name
Old Address
City State Zip
New Address
City State Zip
VOL. 87— NUMBER 12 DECEMBER 1990
1039
) 'Yll)7 Hahnemann
JJlXTl1 University
Department of Medicine
GRAND ROUNDS
WEDNESDAYS
8:30 a. m. -9:30 a.m.
December, 1990
December 5, 1990
PTCA VS BYPASS GRAFT SURGERY FOR CORONARY
ARTERY DISEASE
William S. Frankl, MD
Vischer Professor of Medicine and Chairman,
Department of Medicine
Director, Likoff Cardiovascular Institute
Hahnemann University
December 12, 1990
ABNORMALITIES OF THROMBOSIS AND
THROMBOEMBOLISM
Daniel Deykin, MD
Chief of Medicine, Director, Health Services
Research and Development
Boston VA Medical Center, MA
December 19, 1990
DIVISION OF PULMONARY MEDICINE AND
CRITICAL CARE
Edward Schulman, MD
Associate Professor of Medicine
Director, Division of Pulmonary and Critical
Care Medicine
Hahnemann Universtiy
WEDNESDAY MEDICAL SEMINAR SERIES
8:30 a.m. -3:30 p.m.
December 12, 1990
ABNORMALITIES OF THROMBOSIS
AND THROMBOEMBOLISM
Seminar Directors:
William S. Frankl, MD
Professor of Medicine
and Chairman
Department of Medicine
Allan B. Schwartz, MD
Professor of Medicine
Director, Continuing
Medical Education for the
Department of Medicine
Location:
Classroom C (Alumni Hall)
2nd FI. New College Bldg.
Hahnemann University
15th Street Entrance
15th & Vine Streets
Philadelphia, PA
As an organization accredited by the Accreditation Council for Continuing Medical
Education (ACCME), Hahnemann University designates this continuing medical
education activity as Category 1 of the Physician's Recognition Award of the
American Medical Association. One credit hour may be claimed for each hour
of participation by the individual physician.
For Information, call the Office of Continuing Education at (215) 448-8263
NEW JERSEY MEDICINE
1040
—
ORTHOPEDICS
25- 4th Annual Obstetrics/
28 Gynecology Update
Stowe, Vermont
(UMDNJ)
28 Nurse Midwifery Program
9 A.M.-5 P.M. — Bally’s Park Place
Casino, Atlantic City
(UMDNJ)
ONCOLOGY
January
11 Tumor Board
11 A.M.-12 Noon — Wallkill Valley
Hospital, Sussex
(AMNJ)
16 Current Chemotherapy
10:30-11:30 A. M. — St. Mary’s
Hospital, Passaic
(AMNJ)
16 Reception
6:30-9:30 P.M. — The Manor,
West Orange
(Radiation Oncology Section,
AMNJ)
24 Tumor Board Conference
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(AMNJ)
February
8 Tumor Board
11 A.M.-12 Noon — Wallkill Valley
Hospital, Sussex
(AMNJ)
28 Dinner Meeting
6:30-9:30 P.M. — The Manor,
West Orange
(Head and Neck Oncology
Section, AMNJ)
28 Tumor Board
12 Noon-1 P.M. — Newcomb
Medical Center, Vineland
(AMNJ)
February
6 Nonoperative Management of
Chronic Back Pain
10:30-11:30 A.M.— St. Mary’s
Hospital, Passaic
(AMNJ)
PEDIATRICS
February
28 Update in Aspects of Pediatrics
6-10 P.M. — Marriott Hotel,
Saddle Brook
(Northern New Jersey
Pediatric Society)
PSYCHIATRY
January
22 Patient Care Monitoring
1:30-3:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(AMNJ)
25 Detoxification: Commonly
Used Drugs
10-11 A.M. — Marlboro Psychiatric
Hospital, Marlboro
(AMNJ)
February
20 Managing Stress Effectively
10:30-11:30 A.M. —St. Mary’s
Hospital, Passaic
(AMNJ)
26 Patient Care Monitoring
1:30-3:30 P.M. — Trenton
Psychiatric Hospital, Trenton
(AMNJ)
RADIOLOGY
January
17 Radiology Meeting
Saint Barnabas Medical Center,
Livingston
(Radiology Society of
New Jersey/ AMNJ)
February
21 Radiology Meeting
Saint Barnabas Medical Center,
Livingston
(Radiology Society of
New Jersey/ AMNJ)
SURGERY AND ITS SPECIALTIES
January
7 Surgical Procedures for Chronic
Pancreatitis
11 A.M.-l P.M. — East Orange
General Hospital,
East Orange
(AMNJ)
10- Sinus Endoscopy
11 7:30 A.M. -4 P.M. — New Jersey
Medical School, Newark
(UMDNJ)
1 1 Postoperative Toxic Shock
Syndrome
12 Noon-1 P.M. — South Jersey
Hospital System, Bridgeton
(AMNJ)
February
10- 12th Annual Vascular
12 Symposium
8 A.M. -4:30 P.M. — Taj Mahal
Hotel & Casino,
Atlantic City
(UMDNJ)
UROLOGY
January
8 Winter Meeting
Holiday Inn, Jamesburg
(Urology Society of New Jersey)
Research in New Jersey
November 1990
Please send $6.50 per copy to:
NEW JERSEY MEDICINE
Two Princess Road
Lawrenceville, NJ 08648
VOL. 87— NUMBER 12 DECEMBER 1990
WWW
1041
wa
Co
So
an
Be
Royal E. Durham. At the grand
age of 96, Royal Elwood Durham,
MD, died on August 30, 1990. Dr.
Durham was a recipient of the
Medical Society of New Jersey
Golden Merit Award in 1965, for 50
years of medical service to his com-
munity. Born in Baltimore,
Maryland, Dr. Durham earned his
medical degree from Jefferson
Medical College, Pennsylvania, in
1915. After completing an in-
ternship at the Episcopal Hospital,
Philadelphia, he served in the
United States Army during World
War I, serving in France and at the
base hospital on the front treating
soldiers with “shell shock.” Upon
his return, he opened a general
medical practice in Atlantic City
from 1919 until his retirement in
1966, and served on the staffs of
Atlantic City Medical Center, and
Shore Memorial Hospital. During
his lengthy career, Dr. Durham
was a member of our Atlantic
County component and of the
AMA.
Basil J. Ellmers. A member of
our Bergen County component,
Basil James Ellmers, MD, died on
June 27, 1990, at the age of 84. Dr.
Ellmers was born in San Pedro, St.
Domingo, on October 3, 1905. Dr.
Ellmers earned his medical degree
from Tufts University School of
Medicine, Boston, in 1931, in-
terned at Hackensack Medical
Center, served a residency at the
former Bergen County Hospital,
and received his New Jersey medi-
cal license in 1933. A general prac-
titioner, Dr. Ellmers practiced in
New Milford and Oradell and was
affiliated with Hackensack Medi-
cal Center and with the former
Bergen County Hospital. He
served as staff president for both
hospitals. Dr. Ellmers was a health
officer in the early 1940s and an
AMA member.
Arthur W. Faust, Jr. Word has
been received of the death of
Arthur William Faust, Jr., MD, on
August 22, 1989. Born in 1918, Dr.
Faust attended Temple University
School of Medicine, earning his
medical degree in 1944. Dr. Faust
served a residency in internal
medicine at the Hospital of Saint
Raphael, New Haven, Connecti-
cut. Dr. Faust pursued a post-
graduate course in internal medi-
cine at the University of Penn-
sylvania Postgraduate School of
Medicine. An internist and
cardiologist, Dr. Faust was af-
filiated with Monmouth Medical
Center, Long Branch, and was a
clinical instructor of internal medi-
cine at Hahnemann Medical Col-
lege, Philadelphia.
Elmer L. Grimes. Founder of
the Medical Inter-Insurance Ex-
change of New Jersey, one of the
first physician-owned medical in-
surance groups in the United
States, Elmer L. Grimes died on
September 20, 1990, of a brain
tumor at the age of 76. Born in
Massachusetts on August 25, 1914,
Dr. Grimes earned his medical
degree from Tufts University
School of Medicine, Boston,
Massachusetts, in 1940. After com-
pleting an internship and resi-
dency at the former Philadelphia
General Hospital, he served a fel-
lowship at Sloan Kettering Cancer
Institute, New York. From 1943 to
1946, Dr. Grimes served as a
pn
h
i
lieutenant in the United States bo
Navy Seabees in the South Pacific. 13
In 1950, Dr. Grimes received his
New Jersey medical license and
became affiliated with two ''
Camden facilities: Our Lady of H
Lourdes Medical Center, and S'
Cooper Hospital/University Medi- K
cal Center. During his career as a 1'
surgeon and medical insurance ex- j j
ecutive, Dr. Grimes served as hos- 1
pital chief of surgery from 1972 to
1982; member and president of the ?
Camden County Medical Society; J
diplomats of the American Board 1
of Surgery; professor of medicine i
at both University of Pennsylvania I
School of Medicine and Jefferson
Hospital Medical College, Phila- i
delphia; governor of the New Jer-
sey chapter of the American Col-
lege of Surgeons; fellow in the
Philadelphia Academy of Surgery;
and member of the AMA.
Thomas C. Hooton. Retired sur-
geon and member of our Essex
County component, Thomas
Campbell Hooton, MD, died on
August 15, 1990, at his home in
San Mateo, California, at the age
of 87. Born in Pensacola, Florida,
in 1902, Dr. Hooton was graduated
from Columbia University College
of Physicians and Surgeons, New
York, in 1932, and then completed
a residency at Bellevue Medical
School, New York. After receiving
his New Jersey medical license in
1935, Dr. Hooton opened a private
surgical practice in Montclair in
1936; for over 50 years he was af-
filiated with The Mountainside
Hospital, Montclair; Saint Barna-
bus Medical Center, Livingston;
and Montclair Community Hospi-
tal. During his career, Dr. Hooton
1042
NEW JERSEY MEDICINE
was chief of staff of Montclair
Community Hospital, fellow of the
Society of Abdominal Surgeons,
and diplomate of the American
Board of Abdominal Surgery.
Samuel J. Mazzotta. Family
practitioner Samuel John Mazzot-
ta, MD, died on June 9, 1990, at
the age of 77. Dr. Mazzotta was
born in Philadelphia on May 11,
1913. After receiving his medical
degree from the State University of
New York, Syracuse, in 1938, Dr.
Mazzotta interned at University
Hospital-SUNY, Syracuse Health
Sciences Center. Dr. Mazzotta
maintained a private practice in
Wildwood Crest and was affiliated
with Burdette Tomlin Memorial
Hospital, Cape May Court House.
Dr. Mazzotta served on the Wild-
wood Crest Board of Health. Dr.
Mazzotta was a captain in the
United States Army from 1940 to
1946, stationed at hospitals in Fort
Dix, New Guinea, and the Philip-
pine Islands and was awarded six
medals and two battle stars for his
service. Dr. Mazzotta was a mem-
ber of the American Medical As-
sociation and of our Cape May
County component, serving as sec-
retary from 1955-1957. Dr. Mazzot-
ta was past-president of the Cape
May County Health Clinic.
James P. Pregnall. At the age
of 83, orthopedic surgeon James
Percy Pregnall, MD, died on Janu-
ary 11, 1990. Dr. Pregnall, born in
Monroe, South Carolina, on April
23, 1906, lived in Richmond, Vir-
ginia, before moving to Allenhurst
in 1936. Dr. Pregnall earned his
medical degree from the Medical
College of Virginia, in 1929. After
serving an internship at New
Haven General Hospital, Con-
necticut, and residencies at Holy
Name Hospital, Teaneck, and
New Haven General Hospital, Dr.
Pregnall received his New Jersey
medical license in 1931. Dr. Preg-
nall maintained a practice in
Asbury Park and was affiliated
with the former Fitkin Memorial
Hi
Hospital, Neptune; Monmouth
Memorial Hospital, Long Branch;
and Jersey Shore Medical Center,
Neptune. Dr. Pregnall retired in
1969. From 1946 to 1947, Dr. Preg-
nall served as president of our
Monmouth County component. He
was a member of the American
Medical Association.
Saul J. Shapiro. Born on Janu-
ary 22, 1910, in New York City,
Saul Joseph Shapiro, MD, died
January 21, 1990, at the age of 79.
After earning his medical degree
from Eclectic Medical College,
Cincinnati, Ohio, in 1935, Dr.
Shapiro interned at Jersey City
Medical Center and earned his
New Jersey medical license in
1936. Dr. Shapiro maintained a
practice in Union City and Atlan-
tic Highlands and was affiliated
with Monmouth Medical Center,
Long Branch. In addition, Dr.
Shapiro, involved in medical ad-
ministration, was a health officer
for the boroughs of Atlantic High-
lands and Highlands and a phy-
sician for the United States Public
Health Service. Dr. Shapiro was a
captain in the United States Army
from 1942 to 1946. Dr. Shapiro was
a member of the American Medi-
cal Association, and of our Mon-
mouth County component.
Kenneth H. Soil. At the un-
timely age of 59, Cherry Hill resi-
dent Kenneth Harvey Soil, MD,
died July 17, 1990. Born in Ches-
ter, Pennsylvania, on July 26,
1930, Dr. Soli earned his medical
degree from Jefferson Medical Col-
lege, Philadelphia, in 1956. Dr.
Soil interned at Thomas Jefferson
University Hospital and served a
fellowship in radiology at Temple
University School of Medicine,
Philadelphia. Dr. Soli received
medical licenses from several
states: Pennsylvania in 1957,
Florida in 1969, New Jersey in
1972, New York in 1976, and Rhode
Island in 1979. A radiologist, Dr.
Soli maintained a practice in
Moorestown and in Rhode Island.
Dr. Soil was a member of our Bur-
lington County component, of our
Camden County component, of the
Rhode Island Medical Society, and
of the Radiological Society of
North America. He was a fellow of
the American College of Radiology.
Herbert A. St. John. Board-
certified internist Herbert Andrew
St. John, MD, died on June 29,
1990, at the age of 71. Born in Rio
Piedras, Puerto Rico, on January
4, 1919, Dr. St. John earned his
medical degree from the University
of Rochester School of Medicine
and Dentistry, New York, in 1945
and his New Jersey medical license
in 1950. Dr. St. John had a private
practice in Old Tappan and was
affiliated with Pascack Valley Hos-
pital, Westwood, and Englewood
Hospital. Dr. St. John was a mem-
ber of our Bergen County compo-
nent and of the American Medical
Association. Dr. St. John served as
captain in the United States Army
Medical Corps from 1946 to 1948.
Pauline Swarm. Public health
pediatrician Pauline Kirksey Alex-
ander Swarm, MD, died on August
19, 1990, at the age of 63. Born on
October 11, 1926, in Fort Smith,
Arkansas, Dr. Swarm received her
medical degree from Washington
University School of Medicine, St.
Louis, Missouri, in 1951, and her
Missouri, Maryland, Ohio, and
New Jersey medical licenses in
1951, 1955, 1965, and 1968, respec-
tively. Dr. Swarm served her in-
ternship and her residency, both in
pediatrics, at St. Louis Children’s
Hospital, St. Louis. Dr. Swarm
served a clinical fellowship at St.
Louis Children’s Hospital and at
Washington University School of
Medicine. A public health pedi-
atrics physician for various boards
of health, Dr. Swarm also main-
tained a practice in Ridgewood.
Dr. Swarm was a professor of pedi-
atrics at the University of Cincin-
nati College of Medicine, Ohio and
a member of our Bergen County
component.
VOL. 87— NUMBER 12 DECEMBER 1990
1043
NEW JERSEY MEDICINE is
the official organ of the Medical
Society of New Jersey. All material
published is copyrighted by
the Medical Society of New
Jersey.
Content. The educational con-
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original concepts relative to
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NEW JERSEY MEDICINE
VOLUME 87: JANUARY TO DECEMBER 1990
NEW JERSEY MEDICINE
Published monthly under the direction of the Committee on Publication
Harry M. Carnes, MD, Chairman
Jerome Abrams, MD, MPH
Richard M. Ball, MD
La Verne Fioretti
Marion Geib
William V. Harrer, MD
Monroe S. Karetzky, MD
Clement H. Kreider, Jr, MD
John H. Lifland, MD
Alan J. Lippman, MD
Charles P. Lisa, MD
Robert M. MacMillan, MD
Helio J. Malinverni, MD
Donald W. Orth, MD
Morris Soled, MD
Louis S. Zeiger, MD
Howard D. Slobodien, MD, Editor-in-Chief
Geraldine R. Hutner, MA, Executive Editor
Nancy M. Propsner, Editorial Assistant
INDEX TO PAGES
Pages
No.
Date
1-72
1
.. January 1990
73-156
2
.. February 1990
157-252
3
.. March 1990
253-356
4
.. April 1990
357-440
5
.. May 1990
441-516
6
.. June 1990
Pages
No.
Date
517-600
7
... July 1990
601-678
8
.. August 1990
679-758
9
.. September 1990
759-842
10 ....
October 1990
843-958
11 ....
.. November 1990
959-1054
12 ....
.. December 1990
Health Access
New Jersey
NEW JE$
MEDICIN1
mess
VOL. 87— NUMBER 12 DECEMBER 1990
1045
INDEX
SUBJECT INDEX
Academy of Medicine of New Jersey
update, 55, 334, 737
AIDS
HIV infection rate, 824
policy, 371
programs, 331
quilt, 262
reporting, 164, 264
squamous cell cancer of the larynx in an intravenous drug
user with AIDS [Barone], 811
Task Force, 332
tuberculosis, AIDS, and IV drug abuse [Lamb], 413
Aneurysm
luetic aortic [McCullough], 409
Asthma
spacer-induced atrial fibrillation [Breeden], 113
Babesiosis
babesiosis (letter), 467
long odyssey [Moss], 291
Biomedical Ethics
Quality of life and health [Hauber], 942
Book Reviews
Aloia JF: Osteoporosis, 700
Andreoli TE: Cecil Essentials of Medicine, 463
Annual Reviews, Inc.: Annual Review of Medicine, 979
Benjamin B: Diagnostic Laryngology, 866
Bielory L: Immunology: 1930-1980: Essays on the History
of Immunology, 980
Bierman CW, Pearlman DS: Allergic Diseases from
Infancy to Adulthood, 623
Brown JL: Pediatric Telephone Medicine. Principles,
Triage, and Advice, 386
Crawford ED, Das S: Current Genitourinary Cancer
Surgery, 699
Curtis BA: Neuroscience: The Basics, 623
Dennen PC: Dennen’s Forceps Deliveries, 385
Dunnihoo DR: Fundamentals of Gynecology and
Obstetrics, 866
Gallin JI, Goldstein IM, Snyderman RO: Inflammation:
Basic Principles and Clinical Correlates, 782
Gazes PC: Clinical Cardiology, Third Edition, 288
Gelder M, Gath D, Mayou R: Oxford Textbook of
Psychiatry, Second Edition, 980
Goldberg S: Coronary Angioplasty, 781
Goldenberg K, Faryna A: Geriatric Medicine for the
House Officer, 623
Goycoolea MV: Atlas of Otologic Surgery, 25
Hood AF, Kwan TH, Burnes DC, Mihm MC: Primer of
Dermatopathology, 99
Jackson EM, Goldner R: Irritant Contact Dermatitis, 537
Kaplan E: Practice Made Perfect, 624
Kaplan HA, Sadock BJ: Comprehensive Textbook of
Psychiatry, 979
Kay AB: Allergy and Asthma: New Trends and
Approaches to Therapy, 463
Kaye R, Oski FA, Barness LA: Core Textbook of
Pediatrics, 781
Kelly WN : Textbook of Internal Medicine, 980
Krause HF: Otolaryngic Allergy and Immunology, 99
Lacher MJ, Redman JR: Hodgkin’s Disease: The
Consequences of Survival, 288
Lerman S, Tripathi RC: Ocular Toxicology, 624
Long WA: Fetal & Neonatal Cardiology, 699
Lufkin RB, Hanafee WN: Pocket Atlas of Head and Neck
MRI Anatomy, 866
McPherson BD, Curtis JE, Loy JW: Social Significance
of Sport, 25
Mink J: MRI of the Musculoskeletal System. A Teaching
File, 782
Morowitz DA: Clinical Implications of Abnormal
Digestive Tract Radiographs, 537
Nordin M, Frankel VH: Basic Biomechanics of the
Musculoskeletal System, 287
O’Byrne PM: Asthma as an Inflammatory Disease, 979
Paul WE: Fundamental Immunology. Second Edition, 185
Plaut TF : Children with Asthma. A Manual for Parents,
287
Pollack HM: Clinical Urography: An Atlas and Textbook
of Urological Imaging, 865
Pomeranz S: Craniospinal Magnetic Resonance Imaging,
699
Rosai J: Ackerman’s Surgical Pathology, 385
Rowland TJ: Pediatric Exercise Science, 99
Runge VM: Enhanced Magnetic Resonance Imaging, 386
Schiavone WA: Nucleus of Cardiac Diagnosis, 464
Schwartz GR, Bircher N, Hanke BK: Emergency
Medicine. The Essential Update, 25
Schwartz M: Designing and Building Your Professional
Office, 185
Sotrel G: Tubal Reconstructive Surgery, 464
Spirduso WW: Physical Activity and Aging, 700
Tetz MR, Apple DJ: The Ocular Fundus, 464
Virella G, Goust J, Fudenberg H: Introduction to Medical
Immunology, 980
Whitehead ED: Current Operative Urology. 1990, 865
Cardiology
innovative methods of cardiac defibrillation [Gessman],
873
laser energy for tachycardia ablation [Saksena], 881
legal implications of routine screening for asymptomatic
silent myocardial ischemia [Smith], 791
luetic aortic aneurysm [McCullough], 409
medical malpractice claims in cardiology [Kuehm], 393
nuclear cardiology [LaManna], 919
Defensive Medicine
clinical decision making [Holtz], 305, 641
confidentiality of peer review, 615
data bank, 455
document restrictions by third-party payors, 532
fee schedules, 767
good Samaritan statute, 689
honest error of judgment rule, 773
legal implications of routine screening for asymptomatic
silent myocardial ischemia [Smith], 791
legal notes, 261, 369
legislative bulletin [O’Hare], 56
Lyme disease: Prevention and control [Curran], 541
maintaining an office laboratory [Voldish], 799
marketing the technologist in the physician office
laboratory [Voldish], 489
medication errors [Boschenstein], 285
medication errors [Kuehm], 27
medical malpractice claims in cardiology [Kuehm], 393
mismedication of the elderly [George], 269
office laboratories [Voldish], 723
PACs, 102
physician assistants, 769
political effectiveness [Hirsch], 17
practicing without a license, 531
PRO legal defense program coverage, 163
professional liability [George], 7, 85, 173, 269, 365, 455,
531,615, 685, 773, 857, 971
1046
NEW JERSEY MEDICINE
INDEX
professional liability insurance [Hirsch], 177, 273
professional medical conduct reform act [Murphy], 989
professional medical conduct reform bill [Grossman] 421
389
professional responsibility, 79
professional review and regulations [George], 983
sexual harassment and discrimination [Shrier], 105
successful partnership [Lichtman], 496
sue judges [George], 7
weight loss programs [Kirschner], 901
Drug Treatment
crack-induced enteric ischemia [Hon], 1001
medication errors [Kuehm], 27
mismedication of the elderly [George], 269
poison information, 370
testing [Slobodien], 381
tuberculosis, AIDS, and IV drug abuse [Lamb], 413
Endarterectomy
carotid endarterectomy [Fried], 795
Fatigue
idiopathic chronic [Van Amberg], 319
Genetic Regulation
antisense DNA-analogs [Ebright], 1011
Handgun Deaths
prevention of (Letter), 283
Health Insurance for the Aged and Disabled, Title 18
attestation form, 79
codes, 525
final payment, 266
HMOs drop from Medicare, 82
reimbursement, 332
Hernias
cancer in inguinal hernias [Knecht], 485
Histiocytoma
malignant fibrous, induced by thorium [DiMarcangelo],
47
Ischemia
small bowel [Hon], 1001
Legislation
bulletin [O’Hare], 56
medical conduct reform act, 983, 989
medical waste regulations [Hogan], 115
PACs, 102
professional conduct medical reform bill [Grossman], 421
Lipomas
colonic, endoscopic, and radiologic characteristics
[Marin], 301
Lyme Disease
clinical manifestations [Sigal], 549
during pregnancy [Edly], 557
immunology [Sigal], 567
in large animals [Post], 575
in New Jersey [Goldoft], 579
in small animals [Lissman], 573
neurological manifestations [Pachner], 563
prevention and control [Curran], 541
psychological impact [Swigar], 544
Magnetic Resonance Imaging
claustrophobia during MR imaging [Granet], 479
Medical Assistance, Title 19
claims payment by direct deposit, 79
Medical Education
allied health education, 853
clinical decision making [Holtz], 305, 641
CME, 371
continuing education calendar, 61, 139, 238, 338, 429, 507,
589, 663, 739, 827, 946, 1037
fun/frustration ratio [Holtz], 262
minority health status in New Jersey [Hampton], 417
responsible weight loss in New Jersey [Kirschner], 901
Medical History
grace under pressure: the first women to join the county
medical societies of New Jersey [Hutner], 187
Hippocrates’ rib [Slobodien], 181
Mesmer, Franz Anton [Parish], 108
Thomas Jefferson University [Saffron], 45
Medical Society of New Jersey
annual meeting application, 51, 137, 231, 823
annual meeting photographs, 667
assessment, 132
auxiliary report [Geib], 55, 235, 333, 425, 504, 586, 737,
941
Bertha, Nicholas A [Propsner], 1009
committees and councils, 1016
editor’s desk [Slobodien], 21, 95, 181, 277, 381, 459, 535,
619, 695, 777, 861,975
Golden Merit Award recipients, 500
Health Access New Jersey, 785
in memoriam, 66, 147, 245, 345, 433, 508, 593, 747, 833,
952, 1042
inaugural address [Costabile], 471
journal award, 369
liaison representatives, 1023
long-range planning, 273
medi-file cards, 451
meeting attendance, 165
new members, 426, 658, 1033
newsletter, 11, 79, 163, 261, 369, 449, 525, 607, 689, 767,
851, 965
nominating committee report, 327
president’s page, 17, 91, 177, 273, 379
retirement seminar, 169
statement of ownership, 938
transactions, 674
trustees’ report, 52, 131, 233, 331, 423, 502, 655, 735, 939,
1029
Melanoma
cancer in inguinal hernias [Knecht], 485
cutaneous malignant [Nwiloh], 121
malignant melanoma of the skin [Mertz], 401
pelvic papillary neoplasia [Peison], 648
research in New Jersey [Hill], 889
Meningitis
Pasteurella multocida [Costa-Cruz], 127
Neonatal Care
surfactant replacement therapy [Greenwald], 931
Neoplasms
biologic therapy of cancer [Dunton], 895
cancer recurrent at stapled colon incision [Davidson], 297
carcinoma of the male breast [Seitzinger], 803
cutaneous malignant melanoma [Nwiloh], 121
familial polyposis coli and Gardner’s syndrome
[Nannery], 731
focal Candida hepatitis in a patient with Richter’s
syndrome [Barone], 727
malignant melanoma of the skin [Mertz], 401
monoclonal antibody therapy of cancer [Goldenberg], 913
pediatric cancer mortality rates [Schneider], 703
pediatric hematology oncology [Donaldson], 927
pelvic papillary neoplasia [Peison], 648
research in New Jersey [Hill], 889
squamous cell cancer of the larynx in an intravenous drug
user with AIDS [Barone], 811
Nuclear Medicine
calcified liver lesions [Jacoby], 651
cardiology [LaManna], 919
VOL 87— NUMBER 12 DECEMBER 1990
1047
INDEX
claustrophobia during MR imaging [Granet], 479
cystic right upper quadrant mass [Jacoby], 498
malignant fibrous histiocytoma induced by thorium
[DiMarcangelo], 47
Obstetrics/Gynecology
communicating after a medical complication, 85
contraceptive use for Planned Parenthood patients
[Savel], 493
couple sues IVF program [George], 366
Kallmann’s syndrome [Goldman], 637
Lyme disease during pregnancy [Edly], 557
mammography regulations, 168
maternal deaths in New Jersey: 1988 [Hansen], 995
reducing the c-section rate, 101
right to refuse cesarean section, 685
Parathyroid Disease
parathyroid adenoma with conflicting parathyroid
hormone levels [Goldman], 815
Peer Review
confidentiality, 615
Pediatrics
cancer mortality rates [Schneider], 703
hematology oncology network [Donaldson], 927
intussusception in childhood [Krasna], 715
Physicians’ Health
contemporary alcoholic [Miller], 35
Pneumothorax
complications of needle EMG of thoracic wall [Miller], 653
OBITUARIES
Practice Opportunities
placement file, 58, 135, 236, 335, 427, 504, 587, 659, 737,
825, 942, 1034
Psychiatry
panic disorder and agoraphobia [Fier], 475
psychological impact of Lyme disease [Swigar], 544
Radiology
calcified liver lesions [Jacoby], 651
cystic right upper quadrant mass [Jacoby], 498
Research
biologic therapy of cancer [Dunton], 895
cancer research [Hill], 889
cardiac defibrillation [Gessman], 873
in New Jersey [Lippman], 871
laser energy for tachycardia ablation [Saksena], 881
monoclonal antibody therapy of cancer [Goldenberg], 913
nuclear cardiology [LaManna], 919
pediatric hematology oncology [Donaldson], 927
sleep medicine [Nahmias], 907
surfactant replacement therapy [Greenwald], 931
vascular surgery and cardiac pacing [Eisenbud], 923
weight loss [Kirschner], 901
Sleep Medicine
research in New Jersey [Nahmias], 907
Surgery
cancer recurrent at stapled colon incision [Davidson], 297
carcinoma of the male breast [Seitzinger], 803
carotid endarterectomy under local anesthesia [Fried], 795
Ackerman, Arthur Fowler, 66
Albano, Frank J, 433
Alexander, John Wesley, 747
Andrus, Robert John, 345
Aptekar, Paul, 508
Babcock, George, Jr, 833
Baime, Jules Edgar, 245
Balsamo, Anthony John, 245
Barnes, Frederick Sheldon, 952
Begen, Frank Robert, 66
Beisler, Lawrence George, 747
Boyd, Robert Peterson, 433
Brache, Anselmo Joseph, 833
Brauer, Selig Leo, 66
Bromley, John Wickliffe, 593
Castaldo, Neil, 508
Clayman, Sigmund Jonas, 245
Colfax, Richard Schoonmaker, 66
Cooper, Jules, 245
Cowen, Mortimer I, 66
Crane, Norman Tompkins, 747
Davis, Harold, 593
De Simone, Louis Edward, 833
Del Vecchio, Alfred, 952
Donahue, Laurence Austin, 345
Durham, Royal Elwood, 1042
Eckhardt, Ralph A, 593
Edlkraut, Edward Coleman, 147
Elkin, Mary Versakos, 345
Ellmers, Basil James, 1042
Falcone, Italo John, 508
Farber, Herbert R, 747
Faust, Arthur William, Jr, 1042
Faux, Frederick John, 952
Fernicola, Anthony Ralph, 433
Finnerty, Urban Raymond, 952
Fleisher, Joseph W, 66
Friedenthal, Bernard, 593
Froix, Cleo Joseph L, 433
Gabe, Jutta Anna, 593
Gamba, Joseph William, 747
Gerard, Arpad G, 748
Goldberg, Harold H, 952
Green, Donald, 345
Griffin, Charles Clayton, 147
Grimes, Elmer L, 1042
Gusack, Floyd Bruce, 147
Hatem, Elias Joseph, 147
Hooton, Thomas Campbell, 1042
Irving, Henry Clay, 67
Jawny, Gregory, 593
Jewell, Edward William, III, 67
Johnson, Herbert, 67
Jones, William Felix, 345
Kaletkowski, Marion Francis, 345
Kim, Young Mook, 833
Kohn, Joseph J, 346
Lauricella, John Patrick, 748
Lewis, Albert, 147
Lipowitz, Melvin W, 508
Lochhead, Harry Burton, 833
Lowenstein, Aaron, 147
Mangelsdorff, Arthur F, 748
Martinez, Jamie, 952
Mazzotta, Samuel John, 1043
McAuliffe, Vincent Joseph, 434
Miller, Helen Lovena, 834
Miller, Robert Thomas, 834
Mireles, Ramiro, 434
Monaghan, James Matthew, 245
Monte, Thomas D, 67
Morrone, Michael James, 748
Murphy, Arthur Gordon, 245
Onorato, Vincenzo Raffaele, 346
Panigrosso, Louis Rocco, 148
Patel, Sushila B, 246
Polk, Charles Carrington, 748
Popenoe, Daniel Ward, 246
Poppick, Harry M, 834
Powers, Robert William, 508
Pregnall, James Percy, 1043
Quinn, Elizabeth Carol, 148
Quirk, Martin Aloysius, 594
Rados, Walter Thomas, 748
Riese, Jacob Atkin, 953
Rosenberg, Louis, 434
Rosendale, Aaron William, 148
Rosner, Edwin R, 953
Sand, Abraham B, 148
Seiler, Francis Ulric, 434
Shapiro, Saul Joseph, 1043
Shope, Edward Pierce Lentz, 148
Shulman, Irving, 148
Sisson, Nelson White, 953
Soil, Kenneth Harvey, 1043
Stanley, Thomas A, 148
Stewart, Walter, 246
St. John, Herbert Andrew, 1043
Swarm, Pauline Kirksey Alexander, 1043
Terreri, D Joseph, 834
Thorpe, James Hancock, 346
Torppey, John Joseph, 346
Trevisan, Louis Alphonse, Jr, 346
Tutela, Arthur Constantine, 434
Venkatesh, Bhatrahally Krishnarao, 594
Vermeulen, Abram, 594
Wayman, Bernard Ralph, 67
Weiser, Edward Harry, 246
Weissberg, William, 434
Welsh, David Harrison, 953
Wilson, David Cole, 246
Winston, Julius, 594
Yaskin, H Edward, 594
Zolli, James Zeno, 834
1048
NEW JERSEY MEDICINE
INDEX
colonic lipomas [Marin], 301
crack-induced enteric ischemia [Hon], 1001
familial polyposis coli and Gardner’s syndrome
[Nannery], 731
intussusception in childhood [Krasna], 715
Whipple operation revisited [Spain], 4l
vascular surgery and cardiac pacing [Eisenbud], 923
Syndromes
Gardner’s syndrome [Nannery], 731
Kallmann’s syndrome [Goldman], 637
Richter’s syndrome [Barone], 727
Tobacco Dependance
controlling tobacco smoke pollution [Slade], 278
AUTHOR INDEX
Abel RM, see McCullough
Abouchedid CA, see Barone JG; see Nannery
Abraham E, see Kuehm
Abrams
Acromegaly (letter), 389
Fundamentals of Gynecology and Obstetrics
(Book Review), 866
Tubal Reconstructive Surgery (Book Review), 464
Alexander J, see Moss
Arlen H
Atlas of Otologic Surgery (Book Review), 25
Diagnostic Laryngology (Book Review), 866
Aronson JE: Core Textbook of Pediatrics
(Book Review), 781
Ball RM: Basic Biomechanics of the Musculoskeletal
System (Book Review), 287
Barone JE, see Barone JG; see Hon
Barone JG, Abouchedid CA, Moser RL: Focal Candida
hepatitis in a patient with Richter’s syndrome, 727
Barone JG, Hutchinson D, Cuppari AL, Barone JE:
Squamous cell cancer of the larynx in an intravenous
drug user with AIDS, 811
Barone JG, see Nannery
Benisch B, see Peison
Benjamin BG, see Krasna
Bergen SS: UMDNJ notes, 53, 132, 234, 332, 424, 503,
585, 658, 824, 840, 1030
Bielory L
Allergic Diseases from Infancy to Adulthood
(Book Review), 623
Allergy and Asthma: New Trends and Approaches to
Therapy (Book Review), 463
Clinical decision making, see Holtz
Fundamental Immunology. Second Edition
(Book Review), 185
Immunology: 1930-1980: Essays on the History of
Immunology (Book Review), 980
Inflammation: Basic Principles and Clinical Correlates
(Book Review), 782
Introduction to Medical Immunology (Book Review),
980
Irritant Contact Dermatitis (Book Review), 537
Ocular Toxicology (Book Review), 624
Otolaryngic Allergy and Immunology (Book Review), 99
Bocage JP, Caccavale R, Lewis R, Sisler G,
MacKenzie J: Tracheal stenosis, 631
Boschenstein FK: Medication errors (letters), 285
Breeden CH, Safirstein BH: Spacer-induced atrial
fibrillation, 113
Brennan RE, see Smith
Caccavale R, see Bocage
Chandler JJ, see Davidson
hazards smokers impose [Ginzel], 311
ode to Koop [Slobodien], 277
Trachea
tracheal stenosis [Bocage], 631
Tuberculosis
AIDS and IV drug abuse [Lamb], 413
UMDNJ
president’s notes [Bergen], 53, 132, 234, 332, 424, 503, 585,
658, 824, 940, 1030
Waste
committee on environmental health, 736
medical waste regulations [Hogan], 115
Chez RA: see Hansen
Cinotti AA: The Ocular Fundus (Book Review), 464
Clay LD, see Davidson
Cohen FB
AMNJ update, 55, 335
Cancer research in New Jersey, 889
Costa-Cruz O, Sesso AM, Mate S, Frank E: Pasteurella
multocida meningitis, 127
Costabile DM: Inaugural address, 471
Coye MJ: C-section reduction project (Letter), 101
Cuppari AL, see Barone JG
Curran AS: Lyme disease: Prevention and control, 541
Dardik H, see Nwiloh
David ET, see DiMarcangelo
Davidson JT, Clay LD, Umanoff M, Chandler JJ:
Cancer recurrent at stapled colon incision, 297
DiMarcangelo MT, David ET, Kuroda K: Malignant
fibrous histiocytoma induced by thorium, 47
Donaldson MH: New Jersey pediatric hematology
oncology, 927
Dooley KH, see Smith
Doyle MJ, see Kuehm
Dunton AW, Hanagan J, Levitt D, Spiegel RJ, Zeffren
J: Biologic therapy of cancer, 895
Ebright Y, Raska K, Gaur S, Frenkel L, Tsao J, Stein
S: Antisense DNA-analogs: Inhibition of human
immunodeficiency virus, 1011
Edly SJ: Lyme disease during pregnancy, 557
Eilers R: Prevention of handgun deaths (letter), 284
Eisenbud DE: Vascular surgery and cardiac pacing, 923
Elias SM, see Fried
Ertel N, see Kirschner
Fier M: Panic disorder and agoraphobia, 475
Frank E, see Costa-Cruz
Frenkel L, see Ebright
Freund N, see Holtz
Fried KS, Elias SM, Raggi R: Carotid endarterectomy
under local anesthesia, 795
Gascon P, see Goldenberg DM
Gaur S, see Ebright
Geib M: MSNJ Auxiliary, 55, 235, 333, 425, 504, 737, 825,
941
Gelber LJ, see Granet
George JE
Emergency Medicine. The Essential Update
(Book Review), 25
Professional liability, 7, 85, 173, 269, 365, 455, 531, 615,
685, 773, 857, 971
George JE, Quattrone MS, Phillips J: Professional
review and regulations, 983
Gessman LJ: Innovative methods of cardiac
defibrillation, 873
VOL. 87— NUMBER 12 DECEMBER 1990
1049
laanaaiiMfcBmMBwn:
INDEX
Ginzel KH: Hazards smokers impose, 311
Gold MS, see Miller
Goldenberg DM, Sharkey RM, Goldenberg H, Hall TC,
Murthy S, Izon DO, Gascon P, Swayne LC:
Monoclonal antibody therapy of cancer, 913
Goldenberg H, see Goldenberg DM
Goldman MH: Acromegaly (letter), 389
Goldman M, Riddle A, Markham E: Kallmann’s
syndrome: Reproductive success, 637
Goldman MH, Suresh A: Parathyroid adenoma, 815
Goldoft MJ, Schulze TL, Parkin WE, Gunn RA: Lyme
disease in New Jersey, 579
Goldstein MH: SBME discipline (letter), 627
Goldstone R: Do we need PACs? (letter), 102
Gorrell J, see Lichtman
Granet RB, Gelber LJ: Claustrophobia during MR
imaging, 479
Greco RS, see Spain
Greenberg MR, see Schneider
Greenwald JR, Hiatt IM, Hegyi T: Surfactant
replacement therapy, 931
Grossman MB
Professional medical conduct reform bill, 421
Reform bill (letter), 390
Gunn RA, see Goldoft
Hall TC, see Goldenberg DM
Hampton G, Morgan DH, Slaughter B: Minority health
status in New Jersey, 417
Hanagan J, see Dunton
Hansen GF: Dennen’s Forceps Deliveries
(Book Review), 385
Hansen GF, Chez RA: Maternal deaths in New Jersey:
1988, 995
Hardy HW, see Hon
Harris C: Charity work by hospital physicians
(letter), 628
Hauber T : Quality of life and health, 942
Haycock CE
Osteoporosis (Book Review), 700
Pediatric Exercise Science (Book Review), 99
Physical Activity and Aging (Book Review), 700
Social Significance of Sport (Book Review), 25
Hegyi T, see Greenwald
Heins A, see Kirschner
Hiatt IM, see Greenwald
Hill AM, Cohen FB: Cancer research in New Jersey, 889
Hirsch PA
President’s page, 17, 91, 177, 273, 379
Hogan EA, McGovern JJ: Medical waste regulations,
115
Holtz H, Bielory L, Freund N, Lasker N: Clinical
decision making, 305
Holtz H, Restifo R: Clinical decision making, 641
Hon DC, Salloum LJ, Hardy HW, Barone JE: Crack-
induced enteric ischemia, 1001
Horner NB
Clinical Urography: An Atlas and Textbook of
Urological Imaging (Book Review), 865
Craniospinal Magnetic Resonance Imaging, 699
MRI of the Musculoskeletal System. A Teaching File
(Book Review), 782
Pocket Atlas of Head and Neck MRI Anatomy
(Book Review), 866
Hutchins JJ: Prevention of handgun deaths (letter), 283
Hutchinson D, see Barone JG
Hutner GR: Grace under pressure: The first women to
join the county medical societies of New Jersey, 187
Izon DO, see Goldenberg DM
Jacoby JH: Cystic right upper quadrant mass, 498
Jacoby JH, O’Brien FX: Calcified liver lesions, 651
Karetzky M, see Nahmias
Kastner T, Luckhardt J: Medical services for the
developmentally disabled, 819
Katcher AL: Pediatric Telephone Medicine. Principles,
Triage, and Advice. (Book Review), 386
Kazem I: Enhanced Magnetic Resonance Imaging
(Book Review), 386
Kirschner MA, Schneider G, Ertel N, Heins A,
McAleavy P, Merrell M: Responsible weight loss in
New Jersey, 901
Knecht JW: Cancer in inguinal hernias, 485
Krasna IH, Benjamin BG, Zitsman JL, Rosenfeld D:
Intussusception in childhood, 715
Kuehm SL, Abraham E: Medical malpractice claims in
cardiology, 393
Kuehm SL, Doyle MJ: Medication errors: 1977 to 1988,
27
Kuroda K, see DiMarcangelo
LaManna M: Nuclear cardiology: Perfusion, viability,
and function, 919
Lamb RJ, Yeh IT: Tuberculosis, AIDS, and PJ drug
abuse, 413
Lasker N, see Holtz
Leonberg SC: Neuroscience: The Basics
(Book Review), 623
Levinson JD: Clinical Implications of Abnormal
Digestive Tract Radiographs (Book Review), 537
Levitt D, see Dunton
Lewis HC, see Mertz
Lewis R, see Bocage
Lichtman S, Gorrell J: A successful partnership, 496
Lieberman JA: Designing and Building Your Professional
Office (Book Review), 185
Lifland JH: Current Operative Urology, 1990
(Book Review), 865
Lippman AJ
Hodgkin’s Disease: The Consequences of Survival
(Book Review), 288
Medical research in New Jersey, 871
Lissman BA: Lyme disease in small animals, 573
Lorber J: MSNJ Auxiliary, 586
Luckhardt J, see Kastner
MacKenzie J, see Bocage
MacMillan RM: Coronary Angioplasty
(Book Review), 781
Maressa VA: Professional medical conduct reform bill
(letter), 390
Marin GA
Annual Review of Medicine (Book Review), 979
Textbook of Internal Medicine (Book Review), 980
Marin GA, Villa GL: Colonic lipomas, endoscopic and
radiologic characteristics, 301
Markham E, see Goldman
Mate S, see Costa-Cruz
McAleavy P, see Kirschner
McCullough JN, Abel RM: Luetic aortic aneurysm, 409
McGovern JJ, see Hogan
Medical Society of New Jersey: Health access New
Jersey, 785
Meinert LA, see Mertz
Merrell M, see Kirschner
Mertz K, Lewis HC, Meinert LA: Malignant melanoma
of the skin, 401
Miller J: Pneumothorax: Complication of needle EMG of
thoracic wall, 653
Miller NS, Gold MS: The contemporary alcoholic, 35
1050
NEW JERSEY MEDICINE
INDEX
Morgan DH, see Hampton
Moser RL, see Barone JG
Moss EG, Alexander J: Noninvasive diagnosis of deep
vein thrombosis, 1005
Moss SW : Long odyssey of babesiosis, 291
Murphy SP: Professional medical conduct reform act,
989
Murthy S, see Goldenberg DM
Nahmias J, Karetzky M: Research in sleep medicine, 907
Nannery WM, Barone JG, Abouchedid CA: Familial
polyposis coli and Gardner’s syndrome, 731
Nwiloh JO, Sussman B, Tambouret R, Dardik H:
Cutaneous malignant melanoma, 121
O’Brien FX, see Jacoby
O’Hare J: Legislative bulletin, 5
O’Neal JR: Reducing the C-section rate (letter), 101
Pachner AR: Neurological manifestations of Lyme
disease, 563
Papa CM: Primer of Dermatopathology
(Book Review), 99
Parish D: Mesmer and his critics, 108
Parkin WE, see Goldoft
Pedinoff A: Children with Asthma. A Manual for Parents
(Book Review), 287
Peison B, Benisch B, Tonzola A: Pelvic papillary
neoplasia along the round ligament simulating inguinal
hernia, 648
Phillips J, see George
Poppick HM: Cecil Essentials of Medicine
(Book Review), 463
Post JE: Lyme disease in large animals, 575
Propsner NM: Profiles in medicine: Nicholas A. Bertha,
MD, 1009
Quattrone MS, see George
Raggi R, see Fried
Raska K, see Ebright
Restifo R, see Holtz
Riddle A, see Goldman
Roberts RM: Babesiosis (letter), 467
Rosenfeld D, see Krasna
Rothfeld EL
Clinical Cardiology, Third Edition (Book Review), 288
Fetal & Neonatal Cardiology (Book Review), 699
Nucleus of Cardiac Diagnosis (Book Review), 464
Rouse AR, see George
Saffron MH: Thomas Jefferson University: Tradition and
heritage, 45
Safirstein BH, see Breeden
Saksena S: Laser energy for tachycardia ablation, 881
Salloum LJ, see Hon
Samuels S: Women in medicine (letter), 467
Savel LE: Contraceptive use for Planned Parenthood
patients, 493
Schneeman NJ, Stein EM: Thrombolytic therapy, 645
Schneider D, Greenberg MR, Stach B: Pediatric cancer
mortality rates in New Jersey and the United States,
703
Schneider G, see Kirschner
Schulze TL, see Goldoft
Seitzinger JW: Carcinoma of the male breast, 803
Sesso AM, see Costa-Cruz
Sharkey RM, see Goldenberg DM
Shrier DK: Sexual harassment and discrimination, 105
Shuster M: Ackerman’s Surgical Pathology
(Book Review), 385
Sigal LH
Clinical manifestations of Lyme disease, 549
Immunology of Lyme disease, 567
Sisler G, see Bocage
Slade JD: Controlling tobacco smoke pollution, 278
Slaughter B, see Hampton
Slobodien HD
editor’s desk, 21, 95, 181, 277, 381, 459, 535, 619, 695,
777, 861,975
handgun deaths (letter), 283
time of lowering expectations, 777
women in medicine (letter), 468
why we need PACs, 103
Smith LG, Brennan RE, Dooley KH: Legal implications
of routine screening for asymptomatic silent myocardial
ischemia, 791
Soled M
Geriatric Medicine for the House Officer
(Book Review), 623
Physicians and patients (letter), 627
Practice Made Perfect (Book Review), 624
Spain DA, Greco RS: Whipple operation revisited, 41
Spiegel RJ, see Dunton
Stach B, see Schneider
Stein EM, see Schneeman
Stein S, see Ebright
Sugerman AA
Comprehensive Textbook of Psychiatry (Book Review),
979
Oxford Textbook of Psychiatry, Second Edition (Book
Review), 980
Suresh A, see Goldman
Sussman B, see Nwiloh
Swayne LC, see Goldenberg DM
Swigar ME: Psychological impact of media coverage, 544
Tambouret R, see Nwiloh
Tonzola A, see Peison
Tsao J, see Ebright
Umanoff M, see Davidson
Van Amberg RJ: Idiopathic chronic fatigue, 319
Villa GL, see Marin
Voldish KL
Maintaining an office laboratory, 799
Marketing the technologist in the physician office
laboratory, 489
Physicians’ office laboratories, 723
Weisslitz W: Asthma as an Inflammatory Disease
(Book Review), 979
Yeh IT, see Lamb
Zitsman JL, see Krasna
Zufall R: Current Genitourinary Cancer Surgery
(Book Review), 699
Zeffren J, see Dunton
Pages
No.
Date
1-72
1
.. January 1990
73-156
2
.. February 1990
157-252
3
.. March 1990
253-356
4
.. April 1990
357-440
5
.. May 1990
441-516
6
.. June 1990
Pages
No.
Date
517-600
7
.. July 1990
601-678
8
.. August 1990
679-758
9
.. September 1990
759-842
10 ....
.. October 1990
843-958
11 ....
.. November 1990
959-1054
12 ....
.. December 1990
VOL. 87— NUMBER 12 DECEMBER 1990
1051
BUYING OR SELLING A PRACTICE?
It is one of the largest and most important business
transactions you will ever make. You can handle it your-
self, spend a great deal of time and energy trying to
make such a sale work, and risk not getting a fair
market price. Or, you can turn to EPSTEIN PRACTICE
BROKERAGE, INC. Our brokerage service includes
consultation, appraisal, screening, and negotiation of
terms. Additionally, we will arrange for institutional
financing.
EPSTEIN PRACTICE BROKERAGE, INC.
16 West Palisade Avenue
Englewood, New Jersey 07631
(201) 568-4933
Route 70 (near Rt. 295) Cherry Hill, NJ
MEDICAL OFFICE
TO SHARE
High visibility. Convenient to several area hospitals.
First floor. Two exam rooms, therapy room, private
office, large business office, plus common reception
area. New decor and furnishings. Flexible availability.
For additional information,
call (609) 429-8899.
DOES YOUR GROUP PRACTICE HAVE
ADEQUATE OFFICE SPACE?
ARE YOU A SOLO PRACTITIONER IN NEED OF
THE BEST MEDICAL OFFICE SPACE?
EAST BRUNSWICK OFFICE — Rent/Purchase/Buy into an es-
tablished practice/Join a group.
Practice in a fully equipped 7,000 sq. ft. medical office large
enough for a group practice of 6 physicians or private enough
for the solo practitioner in each section.
X-ray machine, stress testing by computer, defribrillator,
rooms fully equipped.
For Cardiologists, Internists, Family Physicians, and Surgeons.
Call Kay at 201-238-6200, or write to:
Ms. Kay Makris, 3 Cornwall Drive
East Brunswick, New Jersey 08816.
MEDICAL OFFICE
FOR SALE OR LEASE
Marlton, NJ area
Route 73 near Marlton Circle
Convenient to area hospitals
5 years old, 1000 SF, 3 exam rooms
Phone system available
For additional information
Call: (609) 596-2233
ASSOCIATE NEEDED
Internist/Primary Care
MICHAELS
EASTON
If you
enjoy mixing
work and a rich
quality of life, then
the golden triangle of
Talbot County, Maryland is
for you. We have rivers and
creeks with beautiful waterfront
homes, boating, and all types of water-
fowl. A variety of cultural events for the
whole family is offered year round. Come visit
and see for yourself; you won’t want to leave.
For more information, please contact:
OXFORD
A. H. Webb, M.D., P.A., 607 Dutchmans Lane, Easton, MD 21601
4 0 8 9
Private Practice
Memorial Hospital
Telephone
301/822-8447
NEW JERSEY MEDICINE
1052
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